Spontaneous intracerebral hemorrhage surgery

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Spontaneous intracerebral hemorrhage surgery

Based on the MIMIC-III database, Yi et al. from the Guangzhou Overseas Chinese Hospital firstly described the dissimilarities in survival probability, mortality, and neurological recovery among mainstream treatments for intracerebral hemorrhage; secondly, patient classification was determined by important clinical features; and outcome variations among treatment groups were compared. The 28-day, 90-day, and in-hospital mortality in the craniotomy group were significantly lower than minimally invasive surgery (MIS) and non-surgical group patients; and, the medium/long-term mortality in the MIS group was significantly lower than the non-surgical group. The craniotomy group positively correlated with short-term GCS recovery compared with the MIS group; no difference existed between the non-surgical and MIS groups. The craniotomy group’s 90-day survival probability and short-term GCS recovery were superior to the other two treatments in the subgroups of first GCS 3-12; this tendency also presented in the MIS group over the non-surgical group. For milder patients (first GCS > 12), the three treatment regimens had a minimal effect on patient survival, but the non-surgical group showed an advantage in short-term GCS recovery. Craniotomy patients have lower mortality and a better short-term neurological recovery in an ICH population, especially in short-to-medium term mortality and short-term neurological recovery over MIS patients. In addition, surgical treatment is recommendable for patients with a GCS ≤ 12. 1).

STITCH

see STITCH.

Randomized controlled trials

see Intracerebral hemorrhage treatment randomized controlled trials.

A better understanding of the pathophysiology of intracerebral hemorrhage (ICH) has led to the identification of several new mechanisms of injury that could be potential therapeutic targets 2).

Minimally invasive surgery (MIS) for the treatment of ICH is the main clinical method that is currently used, despite the lack of large-scale, clinical, multi-center, randomized controlled trials 3).

Indications

see Intracerebral hemorrhage surgery indications.

Techniques

Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH. Other methods include endoscopic hemorrhage aspiration, use of fibrinolytic therapy to dissolve the clot followed by aspiration, and CT-guided stereotactic aspiration 4) 5).

Intracerebral hemorrhage minimally invasive surgery

see Intracerebral hemorrhage minimally invasive surgery

Endoscopic surgery for intracerebral hemorrhage

see Endoscopic surgery for intracerebral hemorrhage

Decompressive hemicraniectomy

Decompressive hemicraniectomy with hematoma evacuation for large ICH might be a safe and effective procedure in patients with severely disturbed consciousness and large hematoma volume 6).

Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting 7) 8)

Early decompressive hemicraniectomy (DH) with or without clot evacuation is feasible and safe for managing spontaneous ICH. The experience of Esquenazi et al. in a uncontrolled retrospective series, the largest such series in the modern era, suggests that it may be of particular benefit in patients with large non-dominant hemisphere ICH who are not moribund at presentation. These findings suggest that a prospective randomized trial of DH vs. craniotomy for ICH be conducted.

Over 7 years, DH was performed in 73 patients with clot evacuation in 86% and DH alone in 14%. The average ICH volume was 81 cc and the median DH surface area was 105 cm(2). 26 patients were comatose at initial presentation. Three-month functional outcomes were favorable in 29%, unfavorable in 44% and 27% of patients expired. Admission Glasgow Coma Scale (p=0.003), dominant hemisphere ICH location (p=0.01) and hematoma volume (p=0.002) contributed significantly to the outcome, as estimated by a multivariate analysis. Eight surgical complications occurred. 9).

Meta-analysis

Intracerebral hemorrhage surgery meta-analysis

References

1)

Yi Y, Che W, Cao Y, Chen F, Liao J, Wang X, Lyu J. Prognostic data analysis of surgical treatments for intracerebral hemorrhage. Neurosurg Rev. 2022 Apr 19. doi: 10.1007/s10143-022-01785-5. Epub ahead of print. PMID: 35441246.
2)

Aiyagari V. The clinical management of acute intracerebral hemorrhage. Expert Rev Neurother. 2015 Dec;15(12):1421-32. doi: 10.1586/14737175.2015.1113876. Epub 2015 Nov 13. PubMed PMID: 26565118.
3)

Wang WM, Jiang C, Bai HM. New Insights in Minimally Invasive Surgery for Intracerebral Hemorrhage. Front Neurol Neurosci. 2015 Nov;37:155-65. doi: 10.1159/000437120. Epub 2015 Nov 12. PubMed PMID: 26588789.
4)

Hersh EH, Gologorsky Y, Chartrain AG, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep. 2018 May 9;18(6):34. doi: 10.1007/s11910-018-0836-4. Review. PubMed PMID: 29740726.
5)

Hanley DF, Thompson RE, Muschelli J, Rosenblum M, McBee N, Lane K, Bistran-Hall AJ, Mayo SW, Keyl P, Gandhi D, Morgan TC, Ullman N, Mould WA, Carhuapoma JR, Kase C, Ziai W, Thompson CB, Yenokyan G, Huang E, Broaddus WC, Graham RS, Aldrich EF, Dodd R, Wijman C, Caron JL, Huang J, Camarata P, Mendelow AD, Gregson B, Janis S, Vespa P, Martin N, Awad I, Zuccarello M; MISTIE Investigators. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol. 2016 Nov;15(12):1228-1237. doi: 10.1016/S1474-4422(16)30234-4. Epub 2016 Oct 11. PubMed PMID: 27751554; PubMed Central PMCID: PMC5154627.
6)

Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus. 2013 May;34(5):E5. doi: 10.3171/2013.2.FOCUS12424. Review. PubMed PMID: 23634924.
7)

Heuts SG, Bruce SS, Zacharia BE, Hickman ZL, Kellner CP, Sussman ES, McDowell MM, Bruce RA, Connolly ES Jr. Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis. Neurosurg Focus. 2013 May;34(5):E4. doi: 10.3171/2013.2.FOCUS1326. PubMed PMID: 23634923.
8)

Bösel J, Zweckberger K, Hacke W. Haemorrhage and hemicraniectomy: refining surgery for stroke. Curr Opin Neurol. 2015 Feb;28(1):16-22. doi: 10.1097/WCO.0000000000000167. PubMed PMID: 25490194.
9)

Esquenazi Y, Savitz SI, Khoury RE, McIntosh MA, Grotta JC, Tandon N. Decompressive hemicraniectomy with or without clot evacuation for large spontaneous supratentorial intracerebral hemorrhages. Clin Neurol Neurosurg. 2015 Jan;128:117-22. doi: 10.1016/j.clineuro.2014.11.015. Epub 2014 Nov 27. PubMed PMID: 25496934.

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