Innovative intensivmedizinische Behandlung neurologischer Patienten

Zusammenfassung

Innovationen der letzten zwei Jahre: Die STICH-I-Studie führte zu einer Reduktion neurochirurgischer Operationen bei Patienten mit intrazerebraler Blutung. STICH II untersucht, ob Patienten mit oberflächlichem Lobärhämatom von einer frühen Operation profitieren. Clazosentan (Endothelinantagonist) war in der Prophylaxe von Vasospasmen nach SAB in der CONSCIOUS-I-Studie sicher und wirksam. Die Phase-III-Studie läuft. fMRI-Studien wiesen bei apallischen Patienten kortikale und subkortikale Aktivierung bei taktilen oder auditiven Stimuli nach. Vereinzelt kann eine tiefe Hirnstimulation der Formatio reticularis zu einer Besserung eines apallischen Syndroms/ minimalen Bewusstseinszustandes führen. Obwohl die Wirksamkeit der Hypothermie nach Reanimation bei Herz-Kreislaufstillstand in einer Studie belegt ist, wird sie noch zu selten angewandt. Die antikörpervermittelte, paraneoplastische juvenile, non-herpetische Enzephalitis stellt eine neue, wichtige Differenzialdiagnose zu schweren Virusenzephalitiden dar. Bei GQ1b-Antikörpersyndromen gibt es eine neu beschriebene Variante, die lediglich zu einer Ophthalmoplegie ohne Areflexie oder Ataxie führt.

Summary

Innovations of the last two years: STICH I led to a reduction of early neurosurgery in patients with intracerebral haemorrhage. The purpose of STICH II is to evaluate the role of early surgery in superficial lobar haematomas. In CONSCIOUS I Clazosentan, an intravenous endothelin receptor antagonist, significantly prevented the occurrence of cerebral vasospasms following a SAH. Currently it is being investigated in a phase III study. fMRI studies demonstrated cortical and subcortical activation to tactile or auditive stimuli in vegetative patients. Deep brain stimulation of the reticular formation may lead to a clinical improvement of those patients. Despite compelling data demonstrated that the use of induced hypothermia can improve survival and neurological recovery after cardiac arrest, this treatment option is underused in physician practice. Antibody-mediated paraneoplastic juvenile non-herpetic encephalitis represents a new differential diagnosis to severe viral encephalitis. Anti-GQ1b antibody syndrome comprises a wide range of diseases. There exists also a novel variant with isolated acute ophthalmoplegia without ataxia or areflexia.

Schlüsselwörter

Intrazerebrale Blutung - Intensivmedizin - Polyneuritis - vegetativer Status

Keywords

Intracerebral hemorrhage - intensive care - polyneuritis - vegetative status

• Literatur

• 1 Bernard S. A, Gray T. W, Buist M. D, Jones B. M, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557-563.
• 2 Coleman M. R, Rodd J. M, Davis M. H, Johnsrude I. S, Menon D. K, Pickard J. D, Owen A. M. Do vegetative patients retain aspects of language comprehension? Evidence from fMRI. Brain 2007; 130: 2494-2507.
• 3 Dalmau J, Tüzün E, Wu H. Y, Masjuan J, Rossi J. E, Voloschin A, Baehring J. M, Shimazaki H, Koide R, King D, Mason W, Sansing L. H, Dichter M. A, Rosenfeld M. R, Lynch D. R. Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol 2007; 61: 25-36.
• 4 de Gans J, van de Beek D. European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347: 1549-1556.
• 5 Desmond R. A, Accortt N. A, Talley L, Villano S. A, Soong S. J, Whitley R. J. Enteroviral meningitis: natural history and outcome of pleconaril therapy. Antimicrob Agents Chemother 2006; 50: 2409-2414.
• 6 Galldicks N, Dohmen C, Neveling M, Fink G. R, Haupt W. F. Selective Immune Adsorption Treatment of Severe Guillain Barré Syndrome in the Intensive Care Unit. Neurocrit Care 2009; 11 (03) 317-321.
• 7 Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: 549-556.
• 8 Kastrau F, Wolter M, Huber W, Block F. Recovery from aphasia after hemicraniectomy for infarction of the speech-dominant hemisphere. Stroke 2005; 36: 825-829.
• 9 Kawai N, Ikematsu H, Iwaki N, Maeda T, Kanazawa H, Kawashima T, Tanaka O, Yamauchi S, Kawamura K, Nagai T, Horii S, Hirotsu N, Kashiwagi S. A comparison of the effectiveness of zanamivir and oseltamivir for the treatment of influenza A and B. J Infect 2008; 56: 51-57.
• 10 Kirkman M. A, Mahattanakul W, Gregson B. A, Mendelow A. D. The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle. Br J Neurosurg 2008; 22: 739-746.
• 11 Lee S. H, Lim G. H, Kim J. S, Oh S. Y, Kim J. K, Cha J. K, Yun C. H, Kang J. K, Lee H, Song H. K, Chung K. C. Acute ophthalmoplegia (without ataxia) associated with anti-GQ1b antibody. Neurology 2008; 71: 426-429.
• 12 Lyden P. D, Shuaib A, Lees K. R, Davalos A, Davis S. M, Diener H. C, Grotta J. C, Ashwood T. J, Hardemark H. G, Svensson H. H, Rodichok L, Wasiewski W. W, Ahlberg G. CHANT Trial Investigators. Safety and tolerability of NXY-059 for acute intracerebral hemorrhage: the CHANT Trial. Stroke 2007; 38: 2262-2299.
• 13 Macdonald R. L, Kassell N. F, Mayer S, Ruefenacht D, Schmiedek P, Weidauer S, Frey A, Roux S, Pasqualin A. CONSCIOUS-1 Investigators. Clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage (CONSCIOUS-1): randomized, double-blind, placebocontrolled phase 2 dose-finding trial. Stroke 2008; 39: 3015-3021.
• 14 Mayer S. A, Brun N. C, Begtrup K, Broderick J, Davis S, Diringer M. N, Skolnick B. E, Steiner T. Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005; 352: 777-785.
• 15 Mendelow A. D, Gregson B. A, Fernandes H. M, Murray G. D, Teasdale G. M, Hope D. T, Karimi A, Shaw M. D, Barer D. H. STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005; 365: 387-397.
• 16 Merchant R. M, Soar J, Skrifvars M. B, Silfvast T, Edelson D. P, Ahmad F, Huang K. N, Khan M, Vanden T. LHoek, Becker L. B, Abella B. S. Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest. Crit Care Med 2006; 34: 1935-1940.
• 17 Nguyen T. H, Tran T. H, Thwaites G, Ly V. C, Dinh X. S, Ho T. NDang, Dang Q. T, Nguyen D. P, Nguyen H. P, To S. D, Nguyen V. C, Nguyen M. D, Campbell J, Schultsz C, Parry C, Torok M. E, White N, Nguyen T. C, Tran T. H, Stepniewska K, Farrar J. J. Dexamethasone in Vietnamese adolescents and adults with bacterial meningitis. N Engl J Med 2007; 357: 2431-2440.
• 18 Sakurai T, Kimura A, Tanaka Y, Hozumi I, Ogura S, Inuzuka T. [Case of adult influenza type A virus-associated encephalopathy successfully treated with primary multidisciplinary treatments] Rinsho Shinkeigaku. 2007; 47: 639-643.
• 19 Schiff N. D, Giacino J. T, Kalmar K, Victor J. D, Baker K, Gerber M, Fritz B, Eisenberg B, Biondi T, O’Connor J, Kobylarz E. J, Farris S, Machado A, McCagg C, Plum F, Fins J. J, Rezai A. R. Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature 2007; 448: 600-603.
• 20 Thwaites G. E, Macmullen-Price J, Tran T. H, Pham P. M, Nguyen T. D, Simmons C. P, White N. J, Tran T. H, Summers D, Farrar J. J. Serial MRI to determine the effect of dexamethasone on the cerebral pathology of tuberculous meningitis: an observational study. Lancet Neurol 2007; 06: 230-236.
• 21 Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, Amelink G. J, Schmiedeck P, Schwab S, Rothwell P. M, Bousser M. G, van der Worp H. B, Hacke W. DECIMAL, DESTINY, and HAMLET investigators. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 06: 215-222.
• 22 Weisfeldt M, Hoogman M, van de Beek D, de Gans J, Dreschler W. A, Schmand B. A. Dexamethasone and long-term outcome in adults with bacterial meningitis. Ann Neurol 2006; 60: 456-468.
• 23 Yamamoto T, Kobayashi K, Kasai M, Oshima H, Fukaya C, Katayama Y. DBS therapy for the vegetative state and minimally conscious state. Acta Neurochir (Suppl) 2005; 93: 101-104.
• 24 Giacino J. T. et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002; 58 (03) 349-353.