Tulosta

Keskivaikeiden ja vaikeiden aivovammojen hoito

Lisätietoa aiheesta
29.12.2017
Jari Siironen, Riikka Takala ja Päivi Tanskanen

Akuuttihoito

Aivovammapotilaan ensihoito

Intubointi

Hypotensio, hypoksia ja ventilaatio

Monitorointi kuljetuksen aikana

Keskivaikeiden ja vaikeiden aivovammojen hoito

Tehohoito

Taulukko 1. Sekundaarivauriota aiheuttavia ja pahentavia tekijöitä.
Hypotensio (RRsys < 120 mmHg, MAP < 80 mmHg) «McHugh GS, Engel DC, Butcher I ym. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:287-93 »2, «Berry C, Ley EJ, Bukur M ym. Redefining hypotension in traumatic brain injury. Injury 2012;43:1833-7 »27, «Wijayatilake DS, Jigajinni SV, Sherren PB. Traumatic brain injury: physiological targets for clinical practice in the prehospital setting and on the Neuro-ICU. Curr Opin Anaesthesiol 2015;28:517-24 »29, «Chesnut RM, Marshall LF, Klauber MR ym. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22 »46
Hypoksia (PaO2 < 8 kPa, SpO2 < 90 %) «McHugh GS, Engel DC, Butcher I ym. Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:287-93 »2, «English SW, Turgeon AF, Owen E ym. Protocol management of severe traumatic brain injury in intensive care units: a systematic review. Neurocrit Care 2013;18:131-42 »43, «Chesnut RM, Marshall LF, Klauber MR ym. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22 »46
Korkea ICP > 20 mmHg «Balestreri M, Czosnyka M, Hutchinson P ym. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 2006;4:8-13 »47, «Treggiari MM, Schutz N, Yanez ND ym. Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Neurocrit Care 2007;6:104-12 »48
Matala aivojen läpivirtauspaine CPP (MAP-ICP) < 60 mmHg «Balestreri M, Czosnyka M, Hutchinson P ym. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 2006;4:8-13 »47
ICP- ja verenpaineanturi nollataan korvakäytävän tasolle todellisen CPP:n arvioimiseksi «Chesnut R, Videtta W, Vespa P ym. Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care 2014;21 Suppl 2:S64-84 »49
Hyperventilaatio «Stocchetti N, Maas AI, Chieregato A ym. Hyperventilation in head injury: a review. Chest 2005;127:1812-27 »50, «Coles JP, Fryer TD, Coleman MR ym. Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 2007;35:568-78 »51
Kuume «Bohman LE, Levine JM. Fever and therapeutic normothermia in severe brain injury: an update. Curr Opin Crit Care 2014;20:182-8 »52
Epileptiset purkaukset ja kouristukset «Hesdorffer DC, Benn EK, Cascino GD ym. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia 2009;50:1102-8 »53, «Rossetti AO, Oddo M. The neuro-ICU patient and electroencephalography paroxysms: if and when to treat. Curr Opin Crit Care 2010;16:105-9 »54, «Pascarella A, Trojano L, Loreto V ym. Long-term outcome of patients with disorders of consciousness with and without epileptiform activity and seizures: a prospective single centre cohort study. J Neu»55
Anemia «Van Beek JG, Mushkudiani NA, Steyerberg EW ym. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:315-28 »56, «Litofsky NS, Martin S, Diaz J ym. The Negative Impact of Anemia in Outcome from Traumatic Brain Injury. World Neurosurg 2016;90:82-90 »57
Koagulopatia «Abdelmalik PA, Boorman DW, Tracy J ym. Acute Traumatic Coagulopathy Accompanying Isolated Traumatic Brain Injury is Associated with Worse Long-Term Functional and Cognitive Outcomes. Neurocrit Care 20»58, «Maegele M, Schöchl H, Menovsky T ym. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017;16:630-647 »59
Hyponatremia «Verbalis JG, Goldsmith SR, Greenberg A ym. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med 2013;126:S1-42 »60
Hypo- ja hyperglykemia «Van Beek JG, Mushkudiani NA, Steyerberg EW ym. Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007;24:315-28 »56, «Liu-DeRyke X, Collingridge DS, Orme J ym. Clinical impact of early hyperglycemia during acute phase of traumatic brain injury. Neurocrit Care 2009;11:151-7 »61, «Griesdale DE, Tremblay MH, McEwen J ym. Glucose control and mortality in patients with severe traumatic brain injury. Neurocrit Care 2009;11:311-6 »62

Sekundaarivauriot

Kuume

Epileptiset purkaukset ja kouristukset

Anemia

Verensokeri

Multimodaalinen monitorointi

Tajunnan tason tarkkailu

Taulukko 2. Puhevasteen arviointi intuboiduilla potilailla. Lähde «Rutledge R, Lentz CW, Fakhry S ym. Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J »98
GCS Motor Score GCS Eye Score
1 2 3 4
1 1 1 1 2
2 1 2 2 2
3 2 2 3 3
4 2 3 3 4
5 3 3 4 4
6 3 4 4 5

Kallonsisäisen paineen (ICP) mittaaminen

Aivojen läpivirtauspaine (Cerebral Perfusion Pressure CPP)

Aivokudoksen happiosapaine

EEG

Muu hoito

Sedaatio ja kivunhoito

Profylaktinen antiepileptinen lääkitys

Kortikosteroidit

Nestehoito

Ravitsemus

Veren hyytymishäiriöiden ja antikoagulaation vaikutus aivovammapotilaan ennusteeseen sekä tromboosiprofylaksian ajoitus

Hypopituitarismi ja hyponatremia

Aivovamman jälkeinen paroksysmaalinen sympaattinen hyperaktiivisuus (PSH)

Kohonneen kallonsisäisen paineen hoito

  • Kohonnut kallonsisäinen paine johtuu kallonsisäisestä tilanahtaudesta. Tämä synnyttää kudossiirtymiä, joka aiheuttavat heikentynyttä aivoverenkiertoa, aivokudoksen hernioitumista ja verisuonten hakautumista. Nämä puolestaan johtavat aivoiskemiaan ja kudosvaurioihin.
  • Ensisijaisena hoitona on poistaa tilaa vievä leesio, jos vain mahdollista, sekä huolehtia riittävästä sedaatiosta, happeutumisesta ja ventilaatiosta.
  • Kouristukset ja kuumeilu voivat myös nostaa kallonsisäistä painetta.

Hypotermia

Hyperosmolaarinen hoito

Hyperventilaatio

Ventrikulostomia

Dekompressiivinen kraniektomia (ks. tarkemmin kirurginen hoito)

  • Dekompressiivista kraniektomiaa käytetään kolmannen tason hoitona (ks. korkean ICP:n hoitoprotokolla) hallitsemattoman korkean ICP:n laskemiseksi.

Korkean icp:n hoitoprotokolla

Vakavien aivovammojen kirurginen hoito

  • Kallonsisäisiä verenvuotoja todetaan noin 60 %:ssa vakavista aivovammoista.
  • HYKS neurokirurgian klinikkaan tulevista vakavan aivovamman saaneista potilaista leikataan tulovaiheessa noin 40 %.
  • Kiistatonta tieteellistä näyttöä hoitomuodoista on vain vähän.
  • Kallonsisäisten verenvuotojen, kuten epiduraalihematooman ja subduraalihematooman kirurginen hoito on hyvin vakiintunutta ja niin yleisesti hyväksyttyä kirurgiaa, että leikkaamatta jättäminen esim. tutkimuksen puitteissa pidettäisiin epäeettisenä.
  • Aivokudoksen sisäisen vuodon kirurgisen hoidon ajoitus ja indikaatiot ovat jäsentymättömämpiä, mutta tällaisetkin vuotopesäkkeet korreloivat huonompaan ennusteeseen ja saattavat laajoina pahentaa sekundaarivauriota.

Yleinen indikaatio kirurgialle

  • Kirurgisen hoidon yleisenä indikaationa on estää sekundaarivaurion kehittyminen, eli kirurgisesti poistetaan vamman aiheuttama tilanahtaus kallon sisältä.
  • Tilanahtaus aiheuttaa kohonneen kallonsisäisen paineen ja kudossiirtymiä, jotka johtavat heikentyneeseen aivoverenkiertoon, aivokudoksen hernioitumiseen ja verisuonten hakautumiseen. Nämä puolestaan johtavat aivoiskemiaan ja kudosvaurioon.
  • Tilanahtaus todetaan joko TT-kuvasta (hematooman koko, sivusiirtymät), mittaamalla kallonsisäistä painetta, tai kliinisten merkkien (aleneva tajunnan taso, vamman puolen mustuaisen laajeneminen, motoriset puolierot) perusteella.
  • Ahtauden syy pitää hoitaa, eli verikertymän aiheuttaessa tilanahtauden ja kohonneen kallonsisäisen paineen, tämä kallon sisälle vuotanut veri poistetaan.
  • Jos ahtauden syynä on aivoturvotus, eikä turvotusta saada konservatiivisin keinoin vähennettyä, tehdään kallon sisälle tilaa poistamalla aivokammion kautta aivo-selkäydinnestettä ventrikulostomialetkun kautta (ks. alla) ja lopulta tarvittaessa poistamalla riittävän suuri osa kallon luuta, jotta saadaan tilaa turvotukselle (dekompressiivinen hemikraniektomia tai bifrontaalinen kraniektomia, ks. alla).

Hallitsemattoman kallonisisäisen paineen kirurginen hoito ilman spesifiä kirurgisesti hoidettavaa syytä

Dekompressiivinen kraniektomia

  • Dekompressiivinen kraniektomia on toimenpide, jossa liian korkean kallonsisäisen paineen hallitsemiseksi poistetaan joko suuri osa kallon luuta keskiviivan toiselta puolelta (hemikraniektomia) tai kallon etuosasta molemmilta puolilta (bifrontaalinen kraniektomia). Luupala säilytetään pakastimessa ja palautetaan paikoilleen erillisessä leikkauksessa potilaan riittävästi toivuttua viikkojen – kuukausien kuluttua.
  • Vaihtoehtoisesti käytetään kaupallisesti juuri sopivaksi valmistettavaa muovista luunkorviketta, biolasia tai titaania.
  • Dekompressiivinen kraniektomia on käytössä ns. malignin aivoinfarktin aiheuttaman turvotuksen hoidossa «Vahedi K, Hofmeijer J, Juettler E ym. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007;6:2»196. Sitä on käytetty yleisemminkin kallonsisäisen tilanahtauden hoitona, kuten myös vammojen aiheuttaman tilanahtauden hoitona.
  • On kuitenkin epäilty, että maksimaalinen kirurginen hoito saattaa johtaa komplikaatioihin ja sitä kautta huonompaan lopputulokseen kuin konservatiivinen hoito ja toisaalta, että henkiin jäävät olisivat liian vakavasti vammautuneita voidakseen elää mielekästä tai tyydyttävää elämää.
  • DECRA-tutkimuksessa «Cooper DJ, Rosenfeld JV, Murray L ym. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364:1493-502 »197 verrattiin dekompressiivisella kraniektomialla hoidettuja vakavan aivovamman saaneita aikuisia konservatiivisin keinoin hoidettuihin.
    • Tulosten perusteella kirurginen hoito johti huonompaan lopputulokseen kuin konservatiivinen hoito.
    • Kirurgisen hoidon kriteerit eivät kuitenkaan vastanneet tyypillisesti käytettäviä kriteerejä, sillä kraniektomia tehtiin hyvin helposti, jos tunnin sisällä kallonsisäinen paine oli 15 minuutin ajan yli 20 mmHg.
    • Lisäksi kirurgisessa ryhmässä oli huomattavasti enemmän potilaita, joiden mustuaisissa ei ollut lainkaan valoreaktioita. Tämä tarkoitti mahdollisesti sitä, että kraniektomia tehtiin ja komplikaatioille altistettiin potilaita, jotka eivät toimenpidettä olisi lopulta tarvinneet ja toisaalta potilaille, joilla mahdollisesti oli palautumaton aivorunkovaurio ilman kovin korkeaa kallonsisäistä painetta.
    • DECRAn tulosten perusteella kliininen käytäntö kuitenkin vaihtui siihen suuntaan, että kovin herkästi tai "ennakoivasti" kraniektomiaa ei vammapotilaille nykyisin tehdä.
  • RESCUE ICP tutkimuksen «Hutchinson PJ, Kolias AG, Timofeev IS ym. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016;375:1119-30 »194 koeasettelu vastaa DECRAa paremmin nykykäytäntöä, jossa kraniektomia tehdään vasta siinä vaiheessa, kun konservatiivinen hoito ei riittävästi tehoa (Rescue ICP:ssä kriteerinä ICP > 25 mmHg yli tunnin ajan).
    • Toimenpiteenä kyseeseen tulee Suomessa tyypillinen hemikraniektomia, mutta useimmiten (63 %) potilaille tehtiin bifrontaalinen kraniektomia.
    • Tulosten mukaan kraniektomia estää tehokkaasti kuolemia 12 kuukauden kohdalla (52 vs. 30,4 %), mutta se samalla lisäsi vegetatiiviseen tilaan jäävien ja vakavasti vammautuneiden määrää (37,6 vs. 19,6 %).
    • Itsenäisesti tuettuna kotona pärjäävien määrä kasvoi kirurgisessa ryhmässä, joskaan täysin itsenäiseen elämään toipuvien määrään toimenpiteellä ei ollut vaikutusta.
    • Huomattavaa on, että alun perin konservatiivisesti hoidetuista potilaista peräti 37 %:lle tehtiin kuitenkin kraniektomia hallitsemattoman kallonsisäisen paineen vuoksi vitaali-indikaatiolla. Tämä on saattanut laimentaa kraniektomian tehoa tuloksia analysoidessa.
    • Yli 40-vuotiaille tehtynä kraniektomia ei näyttänyt olevan lainkaan niin vaikuttava toimenpide kuin sitä nuoremmille.

Ventrikulostomia

Spesifit indikaatiot kirurgialle

Aivokudoksen sisäiset verenpurkaumat

  • Vamman aiheuttama verenpurkauma aivokudoksen sisällä saatetaan poistaa, jos verenpurkauma on kookas, pinnallinen, jos tajunnan taso vaikuttaa vuodon tai ruhjeen vuoksi huononevan ja/tai potilaalla on etenevä neurologinen oire, joka todennäköisesti on hematooman aiheuttama.
  • Poistettavaksi suositellaan tajuttoman potilaan otsa- tai ohimolohkossa sijaitseva, yli 20 ml verenpurkauma/mustelma/kontuusiopesäke, joka aiheuttaa yli 5 mm keskiviivasiirtymän ja/tai basaalisisternojen komprimoitumisen TT-kuvassa «Bullock MR, Chesnut R, Ghajar J ym. Surgical management of traumatic parenchymal lesions. Neurosurgery 2006;58:S25-46; discussion Si-iv »198.
  • Tarkempia indikaatioita pyrittiin selvittämään satunnaistetulla ns. TICH-tutkimuksella, johon otettiin potilaita, joista hoitava neurokirurgi ei ollut varma siitä, onko kirurginen vai konservatiivinen hoito parempi «Mendelow AD, Gregson BA, Rowan EN ym. Early Surgery versus Initial Conservative Treatment in Patients with Traumatic Intracerebral Hemorrhage (STITCH[Trauma]): The First Randomized Trial. J Neurotraum»199. Käytännössä myös aiempaa pienemmät, jo yli 10 ml hematoomat ja hematoomat aiempia indikaatioita parempikuntoisilla potilailla kuuluivat tutkimuksessa operatiivisen hoidon piiriin.
    • Tutkimus jouduttiin keskeyttämään rahoittajan lopettaessa tutkimuksen liian vähäisen potilaiden kertymisen vuoksi. Tarkoitus oli kerätä 840 potilasta, mutta lopulta saatiin kerättyä vain 170 potilasta 31 eri keskuksesta.
    • Keskeneräisten tulosten mukaan kuolleisuus 6 kuukauden kohdalla kirurgisessa ryhmässä oli 15 % ja konservatiivisen hoidon ryhmässä 33 %. Samansuuntaisesti suotuisa toipuminen katsottiin olevan kirurgisessa ryhmässä 63 %:lla, konservatiivisessa ryhmässä 53 %:lla.
    • Keskeytymisen vuoksi yllä mainittu tulos saattaa kuitenkin johtua sattumastakin.
    • Huomattavaa on, että 31 potilasta alkuperäisestä 75 potilaan konservatiivisen hoidon ryhmästä päätyi kuitenkin kirurgiseen hoitoon. Ottaen huomioon tämän siirtymän tuloksia potentiaalisesti laimentavan vaikutuksen (koska puolet konservatiivisestakin ryhmästä sai leikkaushoidon) ja sen, että tutkimukseen valittiin vain potilaita, joita hoitava neurokirurgi ei edes katsonut selkeästi leikattavaksi, tukee TICH-tutkimus tällaisenaankin aivokudoksen sisäisten vuotojen operatiivista hoitoa.
    • Kesken jääneen tutkimuksen mukaan vaikuttaa siltä, että aktiivinen 12 tunnin sisällä tapahtuva traumaattisen aivokudoksen sisäisen verenkertymän poisto olisi potilasta hyödyttävä toimenpide potilailla, joiden GCS on 9–12.

Kovakalvon alainen verenpurkauma

  • Verenvuoto saa yleensä alkunsa aivon pinnan laskimosta, ja veri vuotaa aivojen pintaa pitkin kovakalvon alla.
  • Subduraalihematoomaan liittyy usein primääri aivokudoksen vamma.
  • Potilaan ajatellaan hyötyvän kovakalvon alaisen veren poistamisesta leikkauksella, jos kovakalvon alainen verenkertymä on paksuudeltaan yli 10 mm tai jos sen aiheuttama sivusiirtymä on yli 5 mm.
  • Veri on yleensä laajana hyytymänä aivojen pinnalla, joten sitä ei saada pois pelkästä poranreiästä (trepanaatio), vaan veri poistetaan kraniotomiateitse eli irroittamalla (tyypillisesti esim. noin 5 cm halkaisijaltaan oleva) luupala (lambeau), joka yleensä asetetaan leikkauksen lopussa takaisin paikoilleen.

Epiduraalihematooma

  • Verenvuoto saa tyypillisesti alkunsa kallonmurtuman aiheuttamasta duran valtimon vauriosta.
  • Vuoto repii kovakalvon irti luusta ja aiheuttaa linssimäisen verenpurkauman luun ja kovakalvon väliin.
  • Vain pienet ja uusintakuvauksessa stabilit hematoomat voidaan hoitaa konservatiivisesti.
  • Tyypillisesti hematooma kasvaa aiheuttaen lisääntyvän tilanahtauden, saman puolen mustuaisen laajenemisen ja tajunnan tason laskun.
  • EDH on kohtuullisen harvinainen, niitä on vain noin 5 % vakavista aivovammoista, mutta sen kirurginen hoito on erityisen olennainen, sillä usein epiduraalihematoomaan ei liity primaaria aivokudoksen vammaa. Jos hematooma poistetaan ajoissa, potilas voi toipua täysin.
  • Kuten kovakalvon alaisessa vuodossa, poistoon tarvitaan kraniotomia, eli irrotetaan hematooman kokoa vastaava luupala, jotta saadaan poistettua duuraa aivoja vasten painava hematoomamassa ja tyypillisesti kohotettua ja kiinnitettyä dura kallon luuhun.
  • Joissain harvoissa tapauksissa, jolloin kraniotomiaa ei pystytä välittömästi tekemään, saattaa potilas hyötyä veren ja paineen osapoistosta trepanaatioreiän kautta ennen varsinaista operaatiota.

Kallonmurtumien kirurginen hoito

  • Kallonmurtumien suurin merkitys on niiden assosiaatio aivokudoksen sisäisiin vammoihin.
  • Yleensä suositellaan operatiivisesti korjaamaan yli kallonluun paksuinen avomurtuma. Tällöin kohotetaan murtuma ja revidoidaan haava.
  • Joskus joudutaan paikkaamaan kraniotomiateitse kallonpohjan murtuman aiheuttama aivo-selkäydinnesteen vuoto esim. nenään tai nieluun asettamalla paikka otsalohkon kaudaaliosan ja luisen kallonpohjan väliin.
  • Jos dura on rikki avomurtumassa, pidetään sitä usein kirurgisen hoidon aiheena.
  • Avomurtumissa ja murtumissa, joihin liittyy aivo-selkäydinnesteen vuotoa, käytetään yleensä profylaktista antibioottia (esim. kefuroksiimi 1,5 g x 3 i.v.), vaikka luotettavia todisteita sen hyödystä ei ole.

Takakuoppavuoto

  • Vamma aiheuttaa vain harvoin (alle 3 % vakavista aivovammoista) kirurgisesti hoidettavia vuotoja takakuopan alueelle.
  • Siellä erityspiirteenä ja leikkauspäätökseen vaikuttavana asiana on vuodon tai turvotuksen 4. ventrikkeliin ja suoraan aivorunkoon aiheuttama kompressio, joiden takia kliininen tilanne saattaa huonontua nopeastikin.
  • 4. ventrikkelin kompressio aiheuttaa aivo-selkäydinnesteen virtauksen patoutumisen kautta kallonsisäisen paineen nousua.
  • Selkeinä leikkausindikaationa on 4. ventrikkelin ahtautumisen aiheuttama hydrokefalus tai aivorunkokompressio.
  • Suositeltu leikkaus on ns. subokkipitaalinen kraniotomia tai kraniektomia eli veren poistaminen. Tämä tehdään tilanteen mukaan mahdollisimman laajasta luuavauksesta, joka joko palautetaan saman tien paikoilleen tai jätetään pois turvotuksen hoitamiseksi.

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