No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Spontaneous supratentorial intracerebral hemorrhage: The role of surgical management
Abstract
Spontaneous supratentorial intracerebral hemorrhage is a vexing clinical problem. Without established guidelines, clinicians are often forced to make case-by-case decisions, based on their own interpretation of relevant studies and experience. A number of randomized studies and several meta-analyses have been unable to provide a clear indication for surgery for this condition. Data from both experimental and clinical studies suggest that early surgical evacuation in some circumstances may be beneficial. This may include a subset of patients with moderate sized hemorrhages and associated moderate neurological deficits; specifically those patients that are likely to survive the primary bleed but with significant permanent neurological deficits. Minimal access surgical techniques may offer advantages over standard large craniotomies, although a role for stereotactic aspirations has not yet been established. The timing of any surgery may also be important with theoretical advantages associated with early and thorough clot evacuation. Future surgical advances will require techniques or adjuvant medical treatment to reduce the occurrence of clot expansion and rebleeding, that have been identified as a source of early deteration and post-operative condition. We review the randomized clinical trials, experimental evidence and management options related to surgical treatment of spontaneous supratentorial intracerebral hemorrhage.
... Brain abscess must be drained, and pneumocephalus must be evacuated if it is under sufficient tension to increase ICP. Surgical management of spontaneous intracerebral bleeding is controversial [77]. ...
Effective management of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. Medical management of increased intracranial pressure should include sedation, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
Background
The goal of this retrospective study was to evaluate the effect of surgical timing on patient outcomes following spontaneous intracerebral hemorrhage (ICH). We also identified risk factors associated with poor prognosis.
Methods
We reviewed all patients who underwent surgery for ICH between January 2014 and January 2021. Outcome was measured using the modified Rankin Scale (mRS) score at 6-month after the surgery. Patients with mRS 0-2 were considered having favorable outcomes and those with mRS 3-5 unfavorable outcomes. The relationships of surgical timing with the risk of unfavorable outcome were identified using the interaction and stratified analyses, generalized additive and logistic regression models. A nomogram was established and evaluated using a receiver operating characteristic curve analysis, plotted decision curve and calibration curve.
Results
We identified 53 patients with favorable outcomes and 144 with unfavorable outcomes. The cases who underwent surgery at >12h and <36h in the favorable outcome group were more than that in the unfavorable outcome group (p<0.001). When the time to operation room (TOR) was less than 21h, shorter TOR was associated with unfavorable outcomes, using the smoothing spline analysis (OR=0.8, p < 0.001). Finally, we developed a nomogram using systolic blood pressure (SBP), Glasgow coma scale (GCS), midline shift, hematoma volume and TOR for predicting the unfavorable outcome. The area under curve (AUC), accuracy, specificity, and sensitivity of nomogram were 0.90, 0.87, 0.72, 0.93 respectively.
Conclusion
Surgical timing between 12 and 26 hours after ICH was associated with favorable outcomes. The nomogram including SBP, GCS, midline shift, hematoma volume and TOR was reliable for predicting ICH outcome.
Coma and anisocoria are the two common signs of a crucial state of neurological dysfunction. The ability to forecast the occurrence of these conditions would help clinicians make clinical risk assessments and decisions.
From October 2006 to September 2008, 118 patients with supratentorial intracerebral hemorrhage (SICH) were enrolled in this retrospective investigation. Patients were distributed into 3 groups according to occurrence of the signs of coma and/or anisocoria in the observation unit during a 30-day period. Group 1 included 52 patients who had normal or impaired consciousness, group 2 included 27 patients who had coma with no anisocoria and group 3 consisted of 39 patients who had coma with anisocoria. The clinical characteristics and parameters on computerized tomography (CT) findings were compared using univariate analysis to determine the factors that were related to the level of consciousness. Logistic regression models established the predictive equations for coma and anisocoria.
Univariate analysis revealed that hematoma volume, the score of intraventricular hemorrhage (IVH score) and the amplitude of midline shift were the factors related to coma and anisocoria. Mean hematoma volume was 24.0 ± 13.0 ml, 53.6 ± 12.6 ml and 80.5 ± 24.6 ml, the mean amplitudes of midline shift were 1.3 ± 2.0 mm, 5.9 ± 4.9 mm and 10.1 ± 5.5 mm, and the mean IVH score was 0.8 ± 1.3, 3.3 ± 3.3 and 5.9 ± 3.4 in groups 1, 2 and 3, respectively. Multivariate analysis showed that hematoma volume and IVH score were independent prognostic factors for coma and anisocoria. The predictive equations for coma and anisocoria were LogitP = 0.279X(HV) + 0.521X(IVH)-18.164 and LogitP = 0.125X(HV)+0.326X(IVH)-6.864, respectively.
Hematoma volume and IVH score were the independent prognostic factors for coma and anisocoria. Logistic regression models established the fitted predictive equations, which could help clinicians make clinical risk assessments and decisions.
Raised intracranial pressure (ICP) is a life threatening condition that is common to many neurological and non-neurological illnesses. Unless recognized and treated early it may cause secondary brain injury due to reduced cerebral perfusion pressure (CPP), and progress to brain herniation and death. Management of raised ICP includes care of airway, ventilation and oxygenation, adequate sedation and analgesia, neutral neck position, head end elevation by 20 degrees-30 degrees, and short-term hyperventilation (to achieve PCO(2) 32-35 mm Hg) and hyperosmolar therapy (mannitol or hypertonic saline) in critically raised ICP. Barbiturate coma, moderate hypothermia and surgical decompression may be helpful in refractory cases. Therapies aimed directly at keeping ICP <20 mmHg have resulted in improved survival and neurological outcome. Emerging evidence suggests that cerebral perfusion pressure targeted therapy may offer better outcome than ICP targeted therapies.
Effective treatment of intracranial hypertension involves meticulous avoidance of factors that precipitate or aggravate increased intracranial pressure. When intracranial pressure becomes elevated, it is important to rule out new mass lesions that should be surgically evacuated. medical management of increased intracranial pressure should include sedation and paralysis, drainage of cerebrospinal fluid, and osmotherapy with either mannitol or hypertonic saline. For intracranial hypertension refractory to initial medical management, barbiturate coma, hypothermia, or decompressive craniectomy should be considered. Steroids are not indicated and may be harmful in the treatment of intracranial hypertension resulting from traumatic brain injury.
To the Editor:
I read with interest Hankey and Hon’s recent review of studies of surgery for primary intracerebral hemorrhage.1 Their systematic review of case series is a novel contribution to the literature. There is some precedent, however, for their meta-analysis of extant randomized controlled trials of surgical versus medical therapy. The authors may have been unaware of my brief meta-analysis of the same 4 trials, published 3 years earlier, as it appeared in a book chapter rather than a Medline article.2 Contrasts between the two meta-analyses are illuminating.
My formal systematic overview examined the clinical end point of mortality rather than the combined clinical end point of death or dependency used by Hankey and Hon. Collating all 4 studies, I found no major effect of surgery, with an odds ratio of fatal outcome of 0.97 (95% confidence interval [CI], 0.64 to 1.48). This finding is similar that of Hankey and Hon for the combined death or dependency …
To overcome the disadvantages of conventional surgery, we developed our own method of computed tomography controlled stereotactic aspiration surgery for hypertensive intracerebral hemorrhage. A new ultrasonic surgical aspirator was also developed to facilitate aspiration of a dense clot in the acute stage. Between 1980 and 1988, 437 patients with hypertensive intracerebral hemorrhage underwent aspiration surgery. Computed tomography controlled stereotactic aspiration surgery can be performed in hematomas of any site or any stage with minimal tissue damage, even in aged patients. Aspiration surgery led to a favorable clinical experience and outcome, especially in the acute stage.
A comparison of the long-term outcome after surgical and nonsurgical treatment of hypertensive putaminal hemorrhage was performed in Japan over the last 15 years to determine the appropriate role of surgery. The overall results show a poor response to surgical treatment, but neurosurgeons also know that hematoma evacuation may bring about a dramatic result in some cases. In addition, experimental studies have shown that hematoma evacuation improves neuronal function at the penumbra. The discrepancy between the results of this study and the neurosurgeon's clinical impression is probably a reflection of the following. In the past, the decision to operate was determined mainly by the location of the hemorrhage as determined by computed tomography and/or magnetic resonance imaging. However, this method of deciding surgical indications is probably not correct. We are trying to change the method of determining the surgical indications from morphological to physiological criteria as follows: All patients are initially treated with hyperbaric oxygen, and those who show improvement of their symptoms are clearly indicated for surgery. If the somatosensory evoked potential or auditory brain stem response shows an improvement after administration of mannitol or glycerol, this is also an indication that surgery should be performed.
This clinical trial investigates the effectiveness of intravenous glycerol therapy in patients with acute cortical infarction in whom intracerebral hemorrhage was rigorously excluded.
Within 48 hours of symptoms from their first ischemic stroke, 113 hospital inpatients were randomized into the trial, provided that hemorrhage was excluded by computed tomography and informed consent was obtained. Patients were stratified into alert, semicoma, and coma groups using the Glasgow Coma Scale. Treatment was allocated according to a double-blind, randomized protocol; 56 patients received 500 mL of 10% glycerol in saline over 4 hours on 6 consecutive days, and 57 patients received corresponding placebo treatment with saline. Using a variety of objective scoring systems, patient follow-up was up to 6 months.
Corresponding measures of outcome in the glycerol and placebo groups were similar. At 6 months, respective mortality rates were 17 of 56 and 16 of 57, and mean +/- SD improvements in scores were 9.98 +/- 14.40 vs 10.51 +/- 12.68 (long-term), 1.12 +/- 7.20 vs 1.57 +/- 6.30 (prognostic), -1.94 +/- 5.53 vs -2.06 +/- 5.34 (Glasgow Coma Scale), and 21.72 +/- 23.40 vs 11.94 +/- 18.10 (Barthel Index rating in survivors). Hemolysis (generally subclinical) was the only adverse effect.
There was no clinically or statistically significant difference in outcome between the groups; a trend toward greater functional recovery among survivors was evident after treatment with glycerol.