Therapie des Patienten mit Polytrauma und Schädel-Hirn-Trauma

Priv.-Doz. Dr. med. Thomas M. FreimanLeitender Oberarzt der Klinik für Neurochirurgie

Klinik für Neurochirurgie (Direktor Prof. Dr. med. Volker Seifert)Zentrum der Neurologie und Neurochirurgie (ZNN)

Therapie des Schädel-Hirn-Traumas (SHT) beim Polytrauma (PT)Inhalt§ Zeitpunkt der OP § Pathologien

§ Schädelfrakturen§ Epiduralhämatom (EDH)§ Akut./chron. Subduralämatom (a/cSDH)§ Contusion§ Hirnödem

§ Pathophysiologie des erhöhten ICPs§ Hemicranictomie

SHT/Polytrauma ManagementPlanung Trepanation: Dauer 1-2 h, Blutverlust 1-2 l§ Rote Phase - Lebensrettung: Luftwege, Kreislauf.

§ Zeit nach Ankunft = 5 – 15 min§ Rö-Thorax, Sono-Abdomen, manuelle Extremitäten-Unters. § Kl. OPs: Thorax-Drainage, Pelvis-Klemme

§ Gelbe Phase – Diagnostik§ t = 5 - 30 min

§ CT: Kopf-Oberschenkel§ Therapieentscheidungen

§ Grüne Phase – OPs§ t = 30 min – Ende

§ Kopf-, Thorax-, Abdomen-, Extremitäten-OPs

Multifokaler OPsParallelversorgung Kopf/Thorax/Abdomen/Gyn/Extremitäten

Fahrzeugunfall: 36 j Frau, Schwangerschaft 35. SSW§ OP Gyn: Kaiserschnitt, Neonatologie: Kindversorgung§ OP Kopf/Hals: Tracheotomie, orale Blutung, ICP, EVD, Hemicranictomie§ OP Thorax/Abdomen: Sectio, Lungenblutung, Leberblutung§ Massentransfusion: 20 EKs, 20 FFPs, 10 TKs

ImpressionsfrakturCoup-Verletzung (direkte Gewalteinwirkung)

§ V.a. Kleinkinder – imprimierter Ping-Pong-Ball§ Bei Duraverletzung „wachsende-Fraktur“ durch § Ind. OP Hebung Fraktur:

§ Offene Fraktur§ Frakt.-Tiefe > Kalottenbreite

FrontobasisfrakturRhinoliquorrhoe

§ Fraktur -> Duraperforation§ Selten spontane Sistierung Rhinoliquorrhoe§ Meningitisgefahr§ Meist OP Ind.: Frontobas. Trep. Dura-Galea-Deckung

# os temp.# S. sphenoidalis

(Keilbeinhöhle)

EpiduralhämatomCoup

§ Ursache: Kalottenfranktur§ Blutung Diploe-Venen§ Blutung A. meningea media

§ Gute Progn., wenn schnelle OP

Akutes Subduralhämatom (aSDH)Contré-Coup (contralaterale Gewalteinwirkung)

§ cCT: taSDH§ Schweres SHT§ Schlechte

Progn.

§ cCT: aSDH§ leichtes SHT

b. Antikoag.

§ Pathol.§ leichtes SHT

b. Antikoag.

Axonale ScherverletzungenSekundäre Traumabewertung

cMRT T2 cMRT Haemo-Sequ. cCT

§ Klin.: Pat. wird nicht wach§ Di.: MRT im Verlauf§ Prognose: ungünstig

Chron. Subduralhämatom (cSDH)Vorausgegangenes Bagatelltrauma § Trauma meist

milde§ 2-6 W vor klin.

Beschwerden§ OP:

Bohrlochtrep.§ sehr gute

Prognose

Progression von KontusionenAusmaß des Neurotraumas initial unklar

§ cCT 1 h nach SHT§ kl. hämorrhag.

Kontusionen § traumat.

Subarachnoidalbl. (tSAB)

§ cCT 4 h nach SHT§ dramat. Zunahme

hämorrhag. Kontus. u. Hirnödem

HC Effektbei verbliebenen Kontusionen/Hirnödem

§ cCT präop4 h nach SHT

§ cCT postop12 h nach SHT

Subacuter posttraumat. HydrocephalusInterstitielles Hirnödem

§ cCT postop 12 h nach SHT

§ cCT postop 7 d § Posttraumat.

Hydrocephalus§ interstitielles

Hirnödem durch Liquordruck

Erhöhter intrakranialler Druck (ICP): Masseneffekt auf das intrakranielle Volumen

ipsilateralMydriasis

kontralateralHemiparese

normal

Fig. Netter, Thieme Verl.

Monro-Kellie-Doktrin:Das intrakranielle Volumen bleibt konstant

Gehirn 95%Gehirn 85%

Liq. 1%Liq. 7.5%Blut 7.5%

Blut 4%

Raumforderndes Ödem

Erhöhter ICPVolumen-Druck Relation

Erhöhter ICPCirculus vitiosus

Raumfordernder Infarkt / Hirnödem

(= MAP - ICP)

Zerebrovaskulärer Widerstanddurch Ausfall Autoregulation

Zerebraler Perfusionsdruck

Zerebraler Blutfluß CBV CPP

ICP

CVR

SHT Konservative/medikamentöse Therapie§ Vermeiden der Hypoxie

§ Intubation GCS < 8§ Vermeiden der Hypotonie

§ MAP > 90 mmHg – CPP > 70 mmHg§ Vermeiden weiterer Blutungen

§ Keine Fremdkörperentfernung§ Ggf. Kopf-Druck-Verband

§ Vermeiden der venösen Congestion§ Oberkörper-Hochlagerung 30°

Hemicraniectomie (HC)Indikationen§ ICP konstant > 25 mm Hg > 1 h

§ Versagen § Medikamentöse Therapie

§ Mannit§ Barbiturate Koma

§ (kleinere) OP§ Externe Ventrikeldrainage (EVD)§ Entlastung Epidural-/Subduralhämatom§ (Extirpation kontusioniertes Gehirn)

HCHautschnitt

2 cm

HCBohrlochtrep., Craniectomie

HCBlutungsgefahr durch Sinuslakunen

§ Trepanantion Mittellinie: Sinusblutungen – RR§ Trepanantion entfernt von Mittellinie: Brückenvenen abgeklemmt

durch Hirnödem

HCDura mater-Eröffnung

HCDuralplastik

HC Effekt auf ICP

Huttner LancetNeurol 2009

HCComorbidität

Risikofaktoren:- Großer Knochendeckel- Devitalisierung durch - Tiefkühlung bei -80° C- oder abdominelle

Implantation s.c.

Autolyse

Kunstknochendeckel3. OP nach SHT

sinking flap-syndrome(eingesunkener Hautlappens)

a

dc

b a

b

c

d

Erste random. HC-Studie b.SHTTaylor et al. 2001

Einschluߧ 1991-1998§ Australien§ 27 Pat.§ nur Kinder§ HC ohne Dura

Eröffnung

Ergebnisse§ HC besseres

Überlben§ HC weniger

Wachkoma

Random. Studie SHT (DECRA)Cooper et al. 2011

n engl j med 364;16 nejm.org april 21, 2011 1493

The new england journal of medicineestablished in 1812 april 21, 2011 vol. 364 no. 16

Decompressive Craniectomy in Diffuse Traumatic Brain InjuryD. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette Murray, B.App.Sci., Yaseen M. Arabi, M.D., Andrew R. Davies, M.B., B.S., Paul D’Urso, Ph.D., Thomas Kossmann, M.D., Jennie Ponsford, Ph.D., Ian Seppelt, M.B., B.S., Peter Reilly, M.D., and Rory Wolfe, Ph.D., for the DECRA Trial Investigators

and the Australian and New Zealand Intensive Care Society Clinical Trials Group*

A bs tr ac t

From the Departments of Intensive Care (D.J.C., L.M., A.R.D.) and Neurosurgery ( J.V.R.), Alfred Hospital; the Depart-ments of Epidemiology and Preventive Medicine (D.J.C., L.M., A.R.D., J.P., R.W.) and Surgery ( J.V.R.), Monash University; the Neurosciences Clinical Institute (P.D.) and the Monash–Epworth Reha-bilitation Research Centre ( J.P.), Epworth Healthcare; and the Epworth Hospital (T.K.) — all in Melbourne, VIC; the De-partment of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, NSW (I.S.); and the Department of Neurosurgery, Royal Adelaide Hospi-tal, Adelaide, SA (P.R.) — all in Australia; and the Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Y.M.A.). Address reprint requests to Dr. Cooper at the Department of Intensive Care, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia, or at jamie.cooper@monash.edu.

*Investigators in the Decompressive Craniectomy (DECRA) trial are listed in the Supplementary Appendix, available at NEJM.org.

This article (10.1056/NEJMoa1102077) was published on March 25, 2011, and updated on November 23, 2011, at NEJM.org.

N Engl J Med 2011;364:1493-502.Copyright © 2011 Massachusetts Medical Society.

BackgroundIt is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

MethodsFrom December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refrac-tory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final pri-mary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.

ResultsPatients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Out-come Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).

ConclusionsIn adults with severe diffuse traumatic brain injury and refractory intracranial hy-pertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.)

The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITAETSBIBLIOTHEK on January 28, 2014. For personal use only. No other uses without permission.

Copyright © 2011 Massachusetts Medical Society. All rights reserved.

n engl j med 364;16 nejm.org april 21, 2011 1493

The new england journal of medicineestablished in 1812 april 21, 2011 vol. 364 no. 16

Decompressive Craniectomy in Diffuse Traumatic Brain InjuryD. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette Murray, B.App.Sci., Yaseen M. Arabi, M.D., Andrew R. Davies, M.B., B.S., Paul D’Urso, Ph.D., Thomas Kossmann, M.D., Jennie Ponsford, Ph.D., Ian Seppelt, M.B., B.S., Peter Reilly, M.D., and Rory Wolfe, Ph.D., for the DECRA Trial Investigators

and the Australian and New Zealand Intensive Care Society Clinical Trials Group*

A bs tr ac t

From the Departments of Intensive Care (D.J.C., L.M., A.R.D.) and Neurosurgery ( J.V.R.), Alfred Hospital; the Depart-ments of Epidemiology and Preventive Medicine (D.J.C., L.M., A.R.D., J.P., R.W.) and Surgery ( J.V.R.), Monash University; the Neurosciences Clinical Institute (P.D.) and the Monash–Epworth Reha-bilitation Research Centre ( J.P.), Epworth Healthcare; and the Epworth Hospital (T.K.) — all in Melbourne, VIC; the De-partment of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, NSW (I.S.); and the Department of Neurosurgery, Royal Adelaide Hospi-tal, Adelaide, SA (P.R.) — all in Australia; and the Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Y.M.A.). Address reprint requests to Dr. Cooper at the Department of Intensive Care, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia, or at jamie.cooper@monash.edu.

*Investigators in the Decompressive Craniectomy (DECRA) trial are listed in the Supplementary Appendix, available at NEJM.org.

This article (10.1056/NEJMoa1102077) was published on March 25, 2011, and updated on November 23, 2011, at NEJM.org.

N Engl J Med 2011;364:1493-502.Copyright © 2011 Massachusetts Medical Society.

BackgroundIt is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

MethodsFrom December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refrac-tory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final pri-mary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.

ResultsPatients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Out-come Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).

ConclusionsIn adults with severe diffuse traumatic brain injury and refractory intracranial hy-pertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.)

The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITAETSBIBLIOTHEK on January 28, 2014. For personal use only. No other uses without permission.

Copyright © 2011 Massachusetts Medical Society. All rights reserved.

Pro DCC§ ICP niedriger§ Beatmungszeit kürzer§ Intensivstation kürzer

Contra DCC§ Glasgow Outcome

Score (GOS) schlechter

§ HC 70% vs. Kons. 51%

§ Höhere Mortalität§ HC 19% vs. Kons. 18% DCCKons. Th.

Neuste Studie HC bei SHT (RESCUE-ICP)Hutchinson et al. 2016

n engl j med 364;16 nejm.org april 21, 2011 1493

The new england journal of medicineestablished in 1812 april 21, 2011 vol. 364 no. 16

Decompressive Craniectomy in Diffuse Traumatic Brain InjuryD. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette Murray, B.App.Sci., Yaseen M. Arabi, M.D., Andrew R. Davies, M.B., B.S., Paul D’Urso, Ph.D., Thomas Kossmann, M.D., Jennie Ponsford, Ph.D., Ian Seppelt, M.B., B.S., Peter Reilly, M.D., and Rory Wolfe, Ph.D., for the DECRA Trial Investigators

and the Australian and New Zealand Intensive Care Society Clinical Trials Group*

A bs tr ac t

From the Departments of Intensive Care (D.J.C., L.M., A.R.D.) and Neurosurgery ( J.V.R.), Alfred Hospital; the Depart-ments of Epidemiology and Preventive Medicine (D.J.C., L.M., A.R.D., J.P., R.W.) and Surgery ( J.V.R.), Monash University; the Neurosciences Clinical Institute (P.D.) and the Monash–Epworth Reha-bilitation Research Centre ( J.P.), Epworth Healthcare; and the Epworth Hospital (T.K.) — all in Melbourne, VIC; the De-partment of Intensive Care Medicine, Nepean Hospital, University of Sydney, Sydney, NSW (I.S.); and the Department of Neurosurgery, Royal Adelaide Hospi-tal, Adelaide, SA (P.R.) — all in Australia; and the Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Y.M.A.). Address reprint requests to Dr. Cooper at the Department of Intensive Care, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia, or at jamie.cooper@monash.edu.

*Investigators in the Decompressive Craniectomy (DECRA) trial are listed in the Supplementary Appendix, available at NEJM.org.

This article (10.1056/NEJMoa1102077) was published on March 25, 2011, and updated on November 23, 2011, at NEJM.org.

N Engl J Med 2011;364:1493-502.Copyright © 2011 Massachusetts Medical Society.

BackgroundIt is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

MethodsFrom December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refrac-tory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final pri-mary outcome was the score on the Extended Glasgow Outcome Scale at 6 months.

ResultsPatients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Out-come Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%).

ConclusionsIn adults with severe diffuse traumatic brain injury and refractory intracranial hy-pertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.)

The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITAETSBIBLIOTHEK on January 28, 2014. For personal use only. No other uses without permission.

Copyright © 2011 Massachusetts Medical Society. All rights reserved.

§ Mortalität HC 30% vs. Kons. 52%

§ Coma vigile HC 6% vs. Kons. 2%

§ Schwerbehinderung HC 18% vs. Kons. 14%

ZusammenfassungSHT beim PT§ Craniotomie dauert 1 h, Blutverlust 1-2 l

§ Pneumo-/Haematothorax/-adomen zuerst/parallel

§ Zügige Evakuation von RF§ OP von EDH, SDH, Impressions#

§ Hemicraniectomie verbessert das Überleben

AusblickSHT beim PT

§ Primärer Hirnschaden nicht behebbar§ Sekundärer Hirschaden behandelbar

§ Blutung, RF, ICP, Ischämie§ Zügiger standardisierter Ablauf der komplexen

Versorgung verbessert Auskommen