PRIMARY INTRACEREBRAL HÆMORRHAGE: A Controlled Trial of Surgical and Conservative Treatment in 180 Unselected Cases

The role of surgery in the treatment of spontaneous intracerebral hemorrhage (ICH) remains controversial. Current recommendations support performing surgery for large or compressive cerebellar hemorrhages. The benefit of surgery for supratentorial ICH has not been definitively demonstrated. Data from the Minimally Invasive Surgery with Thrombolysis in Intracerebral Hemorrhage Evacuation (MISTIE) trials and other studies suggest that effective removal of the blood clot may decrease perihematomal edema and improve outcomes in a dose-dependent fashion. With this knowledge, a wave of new minimally invasive evacuation studies is underway or under development to further explore this treatment strategy in a devastating form of stroke with few existing treatment options.

Decompressive hemicraniectomy (DH) effectively alleviates increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) and malignant middle cerebral artery (MCA) infarction. Its role in the management of spontaneous intracranial hemorrhage (SICH) however remains uncertain. This study aims to review the efficacy and safety of DH without clot evacuation in SICH.

A systematic literature search of PubMEd, EMBASE, Scopus and Cochrane Library Central Register of Control Trials was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and end points. Primary endpoint was overall mortality. Secondary endpoint was functional outcome using modified Rankin scale (mRs) or Glasgow outcome scale (GOS).

Nine studies with a total of 146 patients who underwent DH without clot evacuation include: 1 RCT, 3 cohort, 2 case series, and 3 case-control studies. Age range was 40–60 years, with majority of patients presenting with a relatively depressed preoperative sensorium (GCS 6–8), large hematoma volumes (>50 mL), and deep locations (basal ganglia and thalamus). Pooled analysis showed a favorable outcome in 53 %, a mortality rate of 26 % and a complication rate of 35.8 %.

DH without clot evacuation may offer functional and mortality benefit in patients with spontaneous ICH, based on limited and heterogeneous studies.

Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.

To delineate the most recommendable treatment of spontaneous intracerebral hemorrhages and the indication for surgery, its timing, and the best surgical technique to be adopted case by case.

Based on PubMed/MEDLINE, Embase, and the Cochrane Library databases, a systematic review of the literature was performed using as keywords the terms "spontaneous intracerebral hemorrhage," "surgical management," "medical management," "supratentorial," and "infratentorial." Because of the highest level of evidence, only randomized and nonrandomized clinical trials, meta-analyses, and comparative cohort studies reported within the last 12 years were selected. An updated and evidence-based treatment algorithm was reported also.

The search initially returned 255 articles. After application of the exclusion criteria, only 19 studies were selected. According to the site and volume of the hematoma, admission Glasgow Coma Scale (GCS) score, and progressive neurologic decline, specific subgroups were identified. Surgery must be considered in patients with an admission GCS score ranging between 5 and 12 and a hematoma volume >30 mL. The best time-window has been reported to be 7–24 hours after ictus. Endoscopic surgery is recommendable for patients with a supratentorial hematoma >60 mL and with a poor GCS score (4–8). Alternative techniques, such as minimally invasive puncture and thrombolysis, may be considered for deeper hematoma.

Careful selection of patients eligible for surgery is mandatory. The optimal timing falls into a time-window ranging between 7 and 24 hours after ictus. Minimal invasive techniques are valuable surgical options for patients in a poor GCS score or harboring large deep-seated hemorrhages.

Surgery for spontaneous primary intracerebral hemorrhage (ICH) remains controversial. Previous surgical trials have primarily focused on short-term mortality while studies on long-term functional outcome are rare. We therefore conducted this retrospective study of long-term outcome on all ICH patients who underwent craniotomy at a single neurosurgical center during a 10-year period.

We included all patients >15 years of age who underwent evacuation of spontaneous ICH at Skåne University Hospital between 2003 and 2012. Case fatality at 30 days, 1 year, and long-term follow-up (up to 10 years) were analyzed in relation to potential predictors of outcome. Long-term functional outcome was assessed in 2013 by telephone interview using the modified Rankin Scale (mRS).

Of 229 operated patients, overall case fatality was 20% at 30 days and 31% at 1 year. For patients with supratentorial ICH, the case fatality was 16% at 30 days and 27% at 1 year, and 29% at 30 days and 41% at 1 year for patients with cerebellar ICH. The most consistent independent predictors of mortality were preictal heart disease and level of consciousness on admission. Of 185 patients with long-term functional outcome available (median follow-up 6.14 years), 44 of them (24%) had a good outcome (mRS score 0–3) and 141 (76%) were severely disabled or dead (mRS score 4–6).

The case fatality in our study was comparatively low, but most survivors lived dependently several years after surgery. Heart disease and level of consciousness were the most consistent predictors of mortality.