Surgical Treatment for ICH

Open Craniotomy with Evacuation of Supratentorial ICH:
Ultra-Early Treatment

Morgenstern LB, Demchuk AM, Kim DH, et al. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology 2001; 56(10): 1294-1299.

• Adult patients within 4 hours of onset of spontaneous supratentorial intracerebral hemorrhage. Comparison made to medical and surgical group treated within 12 hour time window.
  • 11 patients treated surgically within 4 hours
  • 12 patients treated surgically within 12 hours
  • 12 patients treated medically within 12 hours
• Outcome: Mortality and functional outcome at 6 months
• Study stopped because of safety concerns
• Rebleeding rate 4 HS 40%, 12 HS 12%.

Outcome	4 HS	12 HS	12 HM
6 month mortality	36	18	29
6 month median BI	75	65	55

 

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Open Craniotomy with Evacuation of Supratentorial ICH:
Acute Worsening

Rabinstein AA, Atkinson JL, Wijdicks EF. Emergency craniotomy in patients worsening due to expanding cerebral hematoma: to what purpose? Neurology. 2002; 58(9): 1325-1326.

• Reviewed 26 cases of spontaneous ICH with acute worsening who had surgery for clot evactuion.
• 56% died, 22% remained severely disabled, 22% regained independence.
• All patients with loss of brainstem reflexes died.

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Endoscopic Aspiration for Supratentorial ICH

Auer LM, Deinsberger W, Neiderkorn K, et al. Endoscopic surgery versus medial treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989; 70: 530-535.

• Inclusion Criteria: Patients with CT confirmed supratentiorial ICH > 10 cc and < 48 hours from time of onset with altered level of consciousness.
  • 50 patients surgical group
  • 50 patients medical group
• Treatment: Endoscopic aspiration of clot
• Outcome: Mortality and disability at 6 months

Results:

	Surgical	Medical
Mortality	42%	70%
Poor Outcome	58%	74%

Odds Ratio of Death and Dependency:
0.46 (0.20-1.04) surgery better

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Meta-analysis

Fernandes HM, Gregson B, Siddique S, et al. Surgery in intracerebral hemorrhage: the uncertainty continues. Stroke. 2000; 31: 2511-2516.

• Meta-analysis of all 7 randomized controlled trials of the effect of surgery after a supratentorial spontaneous ICH.
  
  
• Meta-analysis of the randomized controlled trials of the effect of surgery after a supratentorial spontaneous ICH to exclude the trial of McKissock et al.
  
  
• Meta-analysis of the randomized controlled trials of the effect of surgery after a supratentorial spontaneous ICH to exclude the trials of McKissock et al and Chen et al.

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Summary of Surgical Treatment for Supratentorial ICH

Several randomized trials with low power have failed to demonstrate benefit associated with surgical evacuation of supratentorial ICH.

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Surgical Evacuation of Cerebellar ICH

• No evidence from randomized trials of benefits of surgical evacuation in ICH.
  
• Evidence mostly in the form of case series.

Study
Kobayaski S, Miyata A, Serizawa T, et al. Treatment of cerebellar hemorrhage—surgical or conservative. Stroke. 1990; 21(8) Suppl: I-62.

• Design: Non-randomized Prospective
• Patients: 75 patients with cerebellar hemorrhage were studied.
  • 45 treated medically
  • 30 treated with decompressive surgery.
• Patients with GCS < 13, and hematoma > 40 mm
• Good outcome occurred 58% with surgery while only 18% with conservative medical therapy

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Ventriculostomy

Adams RE, Diringer MN. Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus. Neurology. 1998; 50: 519-523.

• Method: Retrospective chart review.
• Inclusion: 24 patients with spontaneous supratentoral ICH who were treated with external ventricular drainage were included.
• Treatment: Ventriculostomy catheter. Best medical care.
• Results 16/22 patients died in hospital. 17/20 patients died at 3 months. 2 were lost to follow-up
• External ventricular drains did not improve hydrocephalus, and changes in ventricular volume did not correlate with changes in level of alertness.

 

The content of these pages was written by Dr. Aninda Acharya of St.Louis University.

Last Revised: August 31, 2002