Überwachung der zerebralen Integrität

 

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Zusammenfassung

Die Überwachung der zerebralen Integrität (zerebrales Neuromonitoring) wird in der Gefäßchirurgie überwiegend bei Operationen mit vorübergehendem Abklemmen einer A. carotis interna benötigt, weil das Gehirn während der Abklemmzeit durch Ischämien und Embolien gefährdet ist. Das Abklemmen einer A. carotis interna führt bei etwa 7 % der Patienten zu Gehirnschäden durch Ischämien und Embolien. Die prophylaktische Anlage eines intraluminären Shunts kann Hirnembolien auslösen und verringert die Komplikationsrate nicht. Die Indikation zur Anlage eines intraluminären Shunts sollte deshalb durch Überwachung der zerebralen Integrität nach Abklemmen einer A. carotis gestellt werden.

Eine invasive Methode zur Abschätzung der Perfusion der betroffenen Gehirnhemisphäre ist die Messung des Blutdrucks im Stumpf der abgeklemmten A. carotis. Die transkranielle Dopplersonographie (TCD) ermöglicht die Messung der mittleren Blutflussgeschwindigkeit in der A. cerebri media. Sie ist relativ ungenau und kann bei etwa 20 % der Patienten aus technischen Gründen nicht durchgeführt werden. Mit der Nah–Infrarot Spektroskopie (NIRS) können Konzentrationsänderungen von Oxyhämoglobin und Desoxyhämoglobin spektroskopisch in einigen Zentimetern Tiefe im Gehirngewebe erfasst werden. NIRS reagiert schnell auf Veränderungen, ist aber noch zu wenig validiert, um allgemein zum Neuromonitoring empfohlen werden zu können.

Somatosensorisch evozierte Potenziale sind aufgrund hoher Genauigkeit und einfacher Anwendung für das Neuromonitoring am weitesten verbreitet. Die Sensitivität und Spezifität für die Diagnose ischämischer Läsionen beträgt 100 % bzw. 94 %–99 %. Deshalb hat sich die Ableitung von somatosensorisch evozierten Potenzialen als Standard in der Überwachung der zerebralen Integrität etabliert.

Abstract

In vascular surgery, intraoperative monitoring of the brain is recommended when the internal carotid artery (ICA) is clamped, because brain damage by ischemia and embolism is possible. Clamping of the ICA results in embolic or ischemic brain lesions in about 7 % of all patients undergoing the procedure. Prophylactic routine insertion of an intraluminal shunt can cause brain embolism and does not reduce the occurrence of complications. Consequently, a shunt should only be inserted, if critical reduction of cerebral perfusion is evident after clamping the ICA. Measurement of carotid stump pressure is an invasive method to estimate perfusion of the brain hemisphere at the clamping side. Transcranial doppler sonography (TCD) measures the mean blood flow velocity in the ACI, but practicability is suffering from technical problems in 20 % of all patients. However, TCD is useful for detecting intraoperative embolism and postoperative hyperperfusion. Changes of oxyhaemoglobine and desoxyhaemoglobine concentration in brain tissue can be measured using near–infrared spectroscopy (NIRS) with wavelengths between 700 and 1000nm. NIRS measurement is easily performed and reacts quickly to changes of brain tissue oxygenation, but there is still lacking evidence and at present a general recommendation of its application in vascular surgery is not justified. Use of somatosensory evoked potentials (SEP) is the most widespread cerebral neuromonitoring during vascular surgery due to its high reliability and simple application. Sensitivity and specifity for ischemic lesions are 100 % and 94 %–99 %, respectively. SEP are regarded as the gold standard for cerebral neuromonitoring in anaesthetized patients.

Kernaussagen

• Das vorübergehende Abklemmen einer A. carotis interna führt bei etwa 7  % der Patienten zu Gehirnschäden durch Ischämien und Embolien.

• Die prophylaktische Anlage eines intraluminären Shunts kann Hirnembolien auslösen und verbessert die Prognose nicht.

• Die Indikation zur Anlage eines intraluminären Shunts sollte durch Überwachung der zerebralen Integrität nach Abklemmen einer A. carotis gestellt werden.

• Die transkranielle Dopplersonografie (TCD) ermöglicht die Erkennung von Embolien und postoperativer Hyperperfusion.

• Die Nah–Infrarot–Spektroskopie (NIRS) misst die Sauerstoffsättigung im Gehirngewebe (70  % venöser Anteil, 30  % arterieller Anteil).

• Somatosensorisch evozierte Potenziale haben die höchste Sensitivität und Spezifität für die Identifizierung von zerebralen Ischämien.

• Die Überwachung der zerebralen Integrität durch somatosensorisch evozierte Potenziale ist auch während Operationen an der thorakalen A. descendens sinnvoll.

• Die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) vergibt ein Zertifikat „Neuromonitoring in Anästhesie und Intensivmedizin” zur Qualitätssicherung.

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PD Dr. med. Berthold Bein
Dr. med. Axel Fudickar
Prof. Dr. med. Jens Scholz

Email: bein@anaesthesie.uni-kiel.de

Email: fudickar@anaesthesie.uni-kiel.de

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