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Medikamentöse Neuroprotektion in der Vestibularisschwannomchirurgie

Neuroprotective medication in vestibular schwannoma surgery

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Zusammenfassung

Hintergrund

Eine spezifische medikamentöse perioperative Neuroprotektion ist in der Neurochirurgie ein ungelöstes Problem.

Ziel der Arbeit

Es wird ein Überblick über klinische Studien gegeben, bei denen der Kalziumantagonist Nimodipin und Hydroxyethylstärke (HES) bei der Resektion von Vestibularisschwannomen (VS) eingesetzt wurden. Darüber hinaus wird auf potenzielle neuroprotektive Wirkmechanismen sowie auf die Übertragbarkeit des Konzepts auf andere Eingriffe mit einem Risiko für eine postoperative Nervenfunktionsverschlechterung eingegangen.

Material und Methoden

Sämtliche 10 in der Datenbank PubMed gelisteten klinischen Studien, die den genannten Kriterien entsprechen, wurden ausgewertet.

Ergebnisse

Vier monozentrische Studien mit intraoperativem Beginn der Medikation zeigten einen positiven Effekt für den Funktionserhalt des N. facialis und für den Erhalt der Hörfunktion. In einer Pilotstudie wurde festgestellt, dass die prophylaktische der intraoperativen Gabe überlegen ist. In einer prospektiven multizentrischen Phase-III-Studie zeigten sich keine signifikanten Ergebnisse. Die Funktion des N. facialis war in beiden Gruppen ein Jahr nach der Operation exzellent. Allerdings war die Wahrscheinlichkeit für einen Hörverlust in der Kontrollgruppe doppelt so hoch. Durch eine Kombination der Daten der multizentrischen Studie mit der dazugehörigen Pilotstudie konnte, am ehesten durch eine Erhöhung der Fallzahl, ein signifikanter Therapieeffekt für den Erhalt des Hörvermögens nachgewiesen werden.

Schlussfolgerung

Bei präoperativ erhaltenem Hörvermögen kann die prophylaktische Gabe von Nimodipin empfohlen werden. Der genaue Wirkmechanismus von Nimodipin und Modifikationen der Prophylaxe sollten weiter untersucht werden.

Abstract

Background

Except for glucocorticoids there is a lack of neuroprotective medication in neurosurgical interventions.

Objective

An overview of clinical trials investigating administration of the calcium antagonist nimodipine and hydroxyethyl starch (HES) in vestibular schwannoma (VS) surgery is given. Basic research is addressed and potential neuroprotective effect mechanisms are discussed, as are perspectives for application of the concept to other types of surgery with a risk postoperative impairment of nerve function.

Materials and methods

A selective PubMed search was performed and all 10 clinical trials corresponding to the search criteria were included.

Results

Four trials with an intraoperative start of the medication showed a positive effect for the preservation of facial nerve function and hearing preservation. A pilot study showed superiority of prophylactic treatment over intraoperative application. There were no significant results in a prospective multicenter phase III trial. After 1 year, postoperative facial nerve preservation rates were excellent in both groups. However, the risk of hearing loss was twice as high in the control group. A combined analysis of the phase III trial with its pilot study showed significant results for better hearing preservation rates in the treatment group (probably by increasing the case load).

Conclusion

Prophylactic nimodipine can be recommended in VS surgery in patients with good preoperative hearing. The effect mechanisms of nimodipine and modifications to prophylaxis should be clarified in basic research.

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Authors and Affiliations

  1. Universitätsklinik und Poliklinik für Neurochirurgie, Universitätsklinikum, Universität Halle-Wittenberg, Halle (Saale), Deutschland

    C. Scheller, E. Herzfeld & C. Strauss

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  1. C. Scheller
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  2. E. Herzfeld
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  3. C. Strauss
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Correspondence to C. Scheller.

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Interessenkonflikt

C. Scheller, E. Herzfeld und C. Strauss geben an, dass kein Interessenkonflikt besteht.

Die klinischen Studien wurden von den Autoren an Menschen nach Genehmigung durch die Ethikkommission durchgeführt. Tierversuche erfolgten nicht.

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Scheller, C., Herzfeld, E. & Strauss, C. Medikamentöse Neuroprotektion in der Vestibularisschwannomchirurgie. HNO 65, 714–718 (2017). https://doi.org/10.1007/s00106-017-0386-0

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