DGI:ZNS-Infektionen/Hirnabszess/Therapie: Difference between revisions

Latest revision as of 20:06, 9 August 2021

Konservative Therapie

Voraussetzungen für ein rein konservatives Vorgehen sind

· Definitive Diagnose

· Kalkulierbarkeit des Erregerspektrums

· Liquorabfluss ist nicht behindert

· Geringe raumfordernde Wirkung bzw. großes perifokales Ödem

Prinzipiell ist ein konservatives Vorgehen gerechtfertigt bei kleinen, multiplen oder sehr tief gelegenen Abszessen. Je weiter der entzündliche Prozess vom Ventrikelsystem entfernt ist, oder wenn sich (noch) keine Ringstruktur nach Kontrastmittel-Gabe zeigt, umso mehr ist ein konservatives Vorgehen angezeigt.

Antibiotikatherapie

· Bei klinisch stabilen Patient:innen Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe

· Wenn eine operative Sanierung nicht binnen weniger Stunden möglich ist, dann Entnahme von Blutkulturen und anschließend Beginn einer empirischen antibiotischen Therapie

· Dauer der antibiotischen Therapie mindestens 6 Wochen, anschließend Verlaufskontrolle mit cMRT

Tabelle: Kalkulierte antibiotische Therapie
Klinische Situation	Präferenz	Substanz	Dosierung	Dauer	Anpassungen	Kommentar
Ohne Operation / Trauma	Therapie der Wahl	Ceftriaxon plus	2x2g i.v.	30d	-
Ohne Operation / Trauma	Therapie der Wahl	Metronidazol	3x500mg i.v.	30d	eGFR > 10ml/min
Nach Trauma / Operation	Therapie der Wahl	Vancomycin plus	2x1g i.v.		eGFR > 50ml/min	Spiegelkontrollen
		Ceftriaxon plus	2x2g i.v.		eGFR > 50ml/min
		Metronidazol	3x500mg i.v.		eGFR > 10ml/min

Abszessaspiration

· Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität

· Geringe Traumatisierung des Hirngewebes

· Nach Möglichkeit Einbringung einer Spüldrainage im Rahmen einer Punktion unter Navigation (sonographisch, stereotaktisch)

Offene Kraniotomie mit Kapselexzision

· Bei gekammertem Abszess

· Wenn sich Fremdkörper im Abszess befinden

· Bei Fisteln oder revisonsbedürftigen Frakturen

@@ Line 1: / Line 1: @@
-==Therapie==
-<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">[24</span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">-26</span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">, 30</span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">]</span>:</span><ref><span style="color: #333333">24. <span style="box-sizing: inherit">       </span> Xu XX, et al., Can diffusion-weighted imaging be used to differentiate brain abscess from other ring-enhancing brain lesions? A meta-analysis. Clin Radiol, 2014; '''69'''(9): 909-15</span></ref><ref><span style="color: #333333">25. <span style="box-sizing: inherit">       </span> Mishra AK, et al., Molecular revolution in the diagnosis of microbial brain abscesses''.'' Eur J Clin Microbiol Infect Dis, 2014; '''33'''(12): 2083-93</span></ref><ref><span style="color: #333333">26. <span style="box-sizing: inherit">       </span> Sonneville R, et al., An update on bacterial brain abscess in immunocompetent patients''.'' Clin Microbiol Infect, 2017; '''23'''(9): 614-620</span></ref><ref><span style="color: #333333">30. <span class="ve-pasteprotect"><span data-ve-attributes="{&quot;style&quot;:&quot;mso-tab-count:1&quot;}" style="box-sizing: inherit">          <span style="box-sizing: inherit"> </span></span></span>Beer R, Lackner P, Pfausler B, Schmutzhard E: Nosocomial ventriculitis and meningitis in neurocritical care patients.</span> <span data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:DE&quot;}" style="box-sizing: inherit"><span class="ve-pasteprotect">J Neurol 2008; 255(11):1617-1624</span></span>
-<span data-ve-attributes="{&quot;style&quot;:&quot;mso-ansi-language:\nDE&quot;}" style="box-sizing: inherit"> </span></ref>
 =====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Konservative Therapie</span>=====
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Voraussetzungen für ein rein konservatives Vorgehen sind</span>
@@ Line 18: / Line 13: @@
 =====Antibiotikatherapie=====
-<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei klinisch stabilen Patienten Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe</span>
+<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei klinisch stabilen Patient:innen Abszessmaterial zur mikrobiologischen Diagnostik vor der ersten Antibiotikagabe</span>
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Wenn eine operative Sanierung nicht binnen weniger Stunden möglich ist, dann Entnahme von Blutkulturen und anschließend Beginn einer empirischen antibiotischen Therapie</span>
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Dauer der antibiotischen Therapie mindestens 6 Wochen, anschließend Verlaufskontrolle mit cMRT</span>
-{| class="wikitable sortable bs-exportable MsoTableGrid" border="1" cellspacing="0" cellpadding="0" width="629" style="box-sizing: inherit; border-collapse: collapse; border-spacing: 0px; background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(51, 51, 51); font-family: &quot;Open Sans&quot;, Roboto, arial, sans-serif; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; margin-left: -0.25pt;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; border-collapse: collapse; border-spacing: 0px; background-color: rgb(255, 255, 255); font-size: 14px; color: rgb(51, 51, 51); font-family: \&quot;Open Sans\&quot;, Roboto, arial, sans-serif; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; margin-left: -0.25pt;&quot;}"
-|+
+{| class="wikitable "
-! style="width:63.8pt;" class="col-grey-light-bg" width="85" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:63.8pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">'''Klinische Situation'''</span>
+|+<span id="Tabelle 5: Kalkulierte antibiotische Therapie">Tabelle: Kalkulierte antibiotische Therapie</span>
-! style="width:63.8pt;" class="col-grey-light-bg" width="85" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:63.8pt;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Präferenz'''</span>
+!Klinische Situation
-! style="width:77.95pt;" class="col-grey-light-bg" width="104" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:77.95pt;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Substanz'''</span>
+!Präferenz
-! style="width:3cm;" class="col-grey-light-bg" width="113" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:3cm;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Dosierung'''</span>
+!Substanz
-! style="width:42.55pt;" class="col-grey-light-bg" width="57" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:42.55pt;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Dauer'''</span>
+!Dosierung
-! style="width:2cm;" class="col-grey-light-bg" width="76" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:2cm;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Anpas-sungen'''</span>
+!Dauer
-! style="width:82.1pt;" class="col-grey-light-bg" width="109" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:82.1pt;&quot;}" |<span class="ve-pasteProtect" style="color: black" data-ve-attributes="{&quot;style&quot;:&quot;color: black&quot;}">'''Kommentar'''</span>
+!Anpassungen
-|- style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"
+!Kommentar
-| style="" data-ve-attributes="{&quot;style&quot;:&quot;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Ohne Operation/ Trauma</span>
+|-
-| style="" data-ve-attributes="{&quot;style&quot;:&quot;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Therapie der Wahl</span>
+! rowspan="2" scope="row" |Ohne Operation / Trauma
-| style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:77.95pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Ceftriaxon</span>
+| rowspan="2" scope="row" |Therapie der Wahl
+|
+Ceftriaxon
 plus
-| style="width:3cm;" width="113" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:3cm;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">2 x 2 g i.v.</span>
+|2x2g i.v.
-| style="width:42.55pt;" width="57" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:42.55pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">30 d</span>
+|30d
-| style="width:2cm;" width="76" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:2cm;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">-</span>
+| -
-| style="width:82.1pt;" width="109" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:82.1pt;&quot;}" |
+|
-|- style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"
+|-
-| style="" data-ve-attributes="{&quot;style&quot;:&quot;&quot;}" |
+|Metronidazol
-| style="" data-ve-attributes="{&quot;style&quot;:&quot;&quot;}" |
+|3x500mg i.v.
-| style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:77.95pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Metronidazol</span>
+|30d
-| style="width:3cm;" width="113" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:3cm;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">3 x 500 mg i.v.</span>
+|eGFR > 10ml/min
-| style="width:42.55pt;" width="57" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:42.55pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">30 d</span>
+|
-| style="width:2cm;" width="76" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:2cm;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">eGFR > 10ml/min</span>
+|-
-| style="width:82.1pt;" width="109" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:82.1pt;&quot;}" |
+! rowspan="3" scope="row" |Nach Trauma / Operation
-|- style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}"
+| rowspan="3" scope="row" |Therapie der Wahl
-| style="width:63.8pt;" width="85" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:63.8pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Nach Trauma/ Operation</span>
+|
-| style="width:63.8pt;" width="85" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:63.8pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Therapie der Wahl</span>
+Vancomycin
-| style="width:77.95pt;" width="104" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:77.95pt;&quot;}" |Vancomycin
 plus
+|2x1g i.v.
+|
+| rowspan="2" scope="row" |eGFR > 50ml/min
+| rowspan="3" scope="row" |Spiegelkontrollen
+|-
+|
 Ceftriaxon
 plus
+|2x2g i.v.
+|-
+|Metronidazol
+|3x500mg i.v.
+|
+|eGFR > 10ml/min
+|}
-Metronidazol
-| style="width:3cm;" width="113" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:3cm;&quot;}" |2 x 1 g i.v.
-x 2 g i.v.
-x 500 mg i.v.
-| style="width:42.55pt;" width="57" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:42.55pt;&quot;}" |
-| style="width:2cm;" width="76" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:2cm;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">eGFR > 50ml/min,</span>
-<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">eGFR > 10ml/min</span>
-| style="width:82.1pt;" width="109" valign="top" data-ve-attributes="{&quot;style&quot;:&quot;width:82.1pt;&quot;}" |<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Spiegel-</span>
-<span class="ve-pasteProtect" style="box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-size: 11pt; font-family: Arial, sans-serif;&quot;}">Kontrollen</span>
-|}
-<span class="col-black ve-pasteProtect" style="color: rgb(0, 0, 0)" data-ve-attributes="{&quot;style&quot;:&quot;color: rgb(0, 0, 0)&quot;}">Tabelle 5: Kalkulierte antibiotische Therapie</span>
 =====<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Abszessaspiration</span>=====
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Relativ kurzer Eingriff mit entsprechend niedriger Operationsletalität und –morbidität</span>
-<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">GeringeTraumatisierung des Hirngewebes</span>
+<span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Geringe Traumatisierung des Hirngewebes</span>
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Nach Möglichkeit Einbringung einer Spüldrainage im Rahmen einer Punktion unter Navigation (sonographisch, stereotaktisch)</span>
@@ Line 88: / Line 81: @@
 <span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Symbol;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Symbol;&quot;}"><span class="ve-pasteProtect" style="box-sizing: inherit;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit;&quot;}">· <span class="ve-pasteProtect" style="box-sizing: inherit; font: 7pt &quot;Times New Roman&quot;;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font: 7pt \&quot;Times New Roman\&quot;;&quot;}">       </span></span></span><span class="ve-pasteProtect" style="box-sizing: inherit; font-family: Arial, sans-serif;" data-ve-attributes="{&quot;style&quot;:&quot;box-sizing: inherit; font-family: Arial, sans-serif;&quot;}">Bei Fisteln oder revisonsbedürftigen Frakturen</span>
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