Surgery for Intracerebral Hemorrhage

Abstract

Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, with 30-day mortality rates of ≈40% and significant morbidity among survivors.1 Progress has proven difficult for this disease state. Unlike ischemic stroke, where incidence seems to be declining in high-wealth countries,2 and subarachnoid hemorrhage, where case fatality has improved,3 there is little evidence that ICH has become less common or less morbid.1 Fortunately, many clinicians and researchers have been unwilling to accept a nihilistic attitude toward parenchymal brain hemorrhage. In the past decade, large trials have tested a variety of treatment approaches for ICH, including neuroprotection,4 blood pressure control,5 hemostatic therapy,6 and surgery.7 Recently, results of the second International Surgical Trial in Intracerebral Hemorrhage (STICH II) were published.8 There are 2 basic rationales for surgical removal of blood after ICH. The first is mechanical: to reduce mass effect, to improve intracranial pressure and brain perfusion, and to prevent dangerous compartment shifts and herniation. The second is chemical: removal of blood products may reduce secondary injury caused by blood breakdown and adverse biochemical or inflammatory processes. Blood removal, however, comes with a price, which typically involves general anesthesia and (in most centers) craniotomy followed by dissection through viable brain to reach the hematoma. This invasive approach to the hematoma is often considered the reason for failure of surgical trials. The concept may be challenged when one considers carefully planned elective procedures such as brain tumor resection, and it may not apply to STICH II, which was limited to superficial hematomas. The urgent removal of a brain hematoma is not a simple matter and requires study on several levels. During …