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Headshaking – Neues in Diagnostik Und Therapie

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Headshaking – Neues in Diagnostik Und Therapie 04.01.2020 Headshaking – Neues in Diagnostik und Therapie K. Feige, T. Puschmann, V. Kopp Klinik für Pferde Stiftung Tierärztliche Hochschule Hannover Headshaking - Allgemeines . Unwillkürliche horizontale, vertikale oder kreisende Bewegungen des Kopfes (Cook, 1979) . Beginn typischerweise mit 7-9- Jahren . 59%-64% sind saisonale HS im Frühjahr bis Sommer . Persistierend oder intermittierend . Häufiger im Trab, seltener im Schritt oder Galopp (Lane & Mair 1987; Newton et al. 2000; Madigan et al. 1995) . 10% nur unter dem Reiter (Madigan & Bell 2001) . Eingeschränkte Reitbarkeit 1 04.01.2020 Headshaking - Histopathologie . Pferde mit idiopathischem HS zeigen degenerative Veränderungen von Axonen und Myelinscheiden des Ggl. trigeminale und des N. trigeminus Festgestellte degenerative Veränderungen können für die Symptomatik des HS verantwortlich sein Trigeminusneuralgie mögliche Ätiologie Idiopathisches Headshaking . Vorschlag zur Neubenennung in 2014: Headshaking ist eine Trigeminus mediierte Erkrankung 6 04.01.2020 Headshaking - Begriffsbestimmung 1. Gelegentliches Schütteln des Kopfes Physiologisches Verhalten oder Abwehrverhalten – kein Headshaking 2. Trigeminus Mediiertes Headshaking (TMHS) Neuropathie des N. trigeminus 3. Nicht-Trigeminus Mediiertes Headshaking (NTMHS) Headshaking - Untersuchungsgang Untersuchungsziel Diagnose der zu Grunde liegenden Krankheit für das TMHS Ausschluss von Nicht-TMHS 7 04.01.2020 Nicht-Trigeminus-Mediiertes-Headshaking Fraktur Proc. paracondylaris Trigeminus-Mediiertes-Headshaking Erschienen in 2019 04.01.2020 18 9 04.01.2020 Trigeminus-Mediiertes-Headshaking Fraktur Os nasale Neuropathie GN 5; Zahnfehlstellung Trigeminus-Mediiertes-Headshaking Neuropathie und Zahnkrankheit Fallserie Klinik für Pferde 61 Pferde mit HS und Zahnkrankheit 9/61 Pferde: HS aufgrund eines (erkrankten) Zahnes 8 Warmblüter, 1 Knabstrupper; 8 Wallache, 1 Stute; 8,3 ± 4,2 Jahre 04.01.2020 10 04.01.2020 FallbeispielTrigeminus-Mediiertes-Headshaking 2 - CT Slapfraktur 108 (P4) Trigeminus-Mediiertes-Headshaking Therapie Zahnkrankheit 3 Pferde Wolfszahn ex 5 Pferde Backenzähne ex 1 Pferd ohne Therapie Therapieerfolg Definition: Kein HS nach Behandlung der Zahnkrankheit Wolfszahn ex: nach 1 bis 14 Tagen symptomfrei Backenzahn ex: nach 1 bis 6 Monaten symptomfrei 04.01.2020 22 11 04.01.2020 Trigeminus-Mediiertes-Headshaking Fraktur Os maxillare Trigeminus-Mediiertes-HeadshakingCT und MRI FLAIR MRT / T2 axial CT Otitis media 12 04.01.2020 Trigeminus-Mediiertes-Headshaking Erhöhte Signalintensität im Sinus frontalis T1 dorsal T2 sagital MRT Untersuchung 13 04.01.2020 MRT - N. maxillaris Stuckenschneider, Dissertation, TIHO 2013 T2 Messung SAP (SEP) • Messung des Schwellen wertes für die Auslösung eines sensomotorischen Aktionspotentials • 6/6 Probanden • Terminale Studie • Reizschwelle für SEP • Krank: ≤ 5 mA • Gesund: ≥ 10 mA • Asaisonal: 7,5 mA 04.01.2020 30 15 04.01.2020 Therapieansätze . Erleichterung der Symptome/ Management . Nasennetz . Augenmaske . Medikamentöse Therapie . Coil - Implantation . Glycerininjektion an das Ganglion trigeminale . (Neurektomie ist obsolet) . Perkutane elektrische Nervenstimulation (PENS) 04.01.2020 33 Nasennetz und Augenmaske 17 04.01.2020 Nasennetz - Therapieerfolg Symptom Reduktion durch ein Nasennetz 100% 90% 80% 70% 60% 40% 0% Kopfschlagen 41 (48%) 27 13 2 1 1 0 Schnauben 23 (43%) 20 7 2 0 0 1 Reiben 45 (59%) 18 9 1 1 1 1 Zügel greifen 28 (73%) 6 3 1 0 0 0 Nasenausflus 7 (54%) 0 1 0 0 0 5 s Husten 0 0 0 1 0 0 4 Tränenfluss 0 2 1 0 0 0 2 Dissertation Rehage, 2007 Medikamentöse Therapie Medikament Dosierung (mg/kg) Applikation Häufigkeit Carbamazepin 2-8 p.o. 2-4 x tgl. Clonidine 0,0025 p.o. 2 x tgl. Cyproheptadine 0,3 p.o. 2 x tgl. Fluphenazin 0,1 i.m. 1-4 Monate Gabapentin 5-20 p.o. 2-3 x tgl. Hydroxyzine 0,6-0,8 p.o. 2 x tgl. Magnesium 20-40 p.o. 1 x tgl. Melatonin 0,03-0,04 p.o. tgl. 17h Phenobarbital 3 p.o. 2 x tgl. Modifizierte Tab. 11.19, Reed/Bayly/Sellon 4. Ed. 2018 04.01.2020 36 18 04.01.2020 Gabapentin Lindert Symptomatik in . hoher Dosierung (2 x tgl. 20 mg/kg p.o.) in Einzelfällen (eigene Daten) Unerwünschte Arzneimittelwirkung . Apathie (Dirikolu et al., 2008) Weitere Medikamente . Glukokortikoide lindern Symptomatik in . Keinem Fall (Mair et al. 1992) . 3 von 20 Fällen (Madigan und Bell 2001) . 50% nach oraler oder intramuskulärer Verabreichung (Pickles et al. 2014) . Cetirizin ist nicht effektiv (Brom-Spierenburg et al., 2018) . NSAIDs, Kortison, Traumeel, Alternativmethoden meist ineffektiv 20 04.01.2020 Coil-Implantation Canalis infraorbitalis Indikation • Wenn Alternative Euthanasie ist • Erfolg bis 84% 04.01.2020 41 Glycerolinjektion Ggl. trigeminale Indikation: • Andere Therapien ineffektiv • Wenn Alternative Euthanasie ist 04.01.2020 42 21 04.01.2020 PENS-Therapie Durchführung . Beidseitig am stehenden Pferd unter Sedierung . Gerät: NeuroStimulator PENS therapy device (Algotec) . Positionierung der PENS-Nadel unter sonographischer Kontrolle . Lokalisation im Bereich For. infraorbitale unmittelbar peripher des N. infraorbitalis . Stimulation des Nerven mit 2 und 100 Hz bei 0.2 bis 2.7 Volt . Wiederholung der Behandlung bei erneutem Auftreten von HS 04.01.2020 45 PENS-Therapie Ergebnisse . Behandlung von 7 Pferden mit trigeminusassoziiertem HS . Behandlung wurde von allen Pferden gut toleriert . 6 Pferde reagierten auf die erste Behandlung erfolgreich . 5 Pferde zeigten einen dauerhaften Therapieerfolg . Dauer des Therapieerfolges . 1. Behandlung: 3.8 [0;8] Tage . 2. Behandlung: 2.5 [0;8] Wochen . 3. Behandlung: 15.5 [0;24] Wochen . 4. Behandlung: 20 [12;28] Wochen 04.01.2020 46 23 .
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