Surgical treatment for spontaneous intracerebral hemorrhage: exploration and evidence-based advances

Article1 October 1952THE NEUROSURGICAL TREATMENT OF SPONTANEOUS INTRACEREBRAL HEMORRHAGE SIMULATING THE COMMON STROKEMICHAEL SCOTT, M.D.MICHAEL SCOTT, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-37-4-751 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe appalling mortality from massive hemorrhage into the cerebrum is common knowledge. The Metropolitan Life Insurance Company in 1946 listed this condition as fourth in the cause of death.1This fact has encouraged neurosurgeons to attempt removal of the clot and control of hemorrhage in selected cases. The results in small series as reported by various neurosurgeons have been encouraging.2-17 This has stimulated the author to operate on a group of carefully selected cases, and then gradually to extend the procedure in some instances to those with grave prognosis with the hope that life might be saved.The first step...Bibliography1. Bulletin, Metropolitan Life Insurance Company, April 29, 1948. Google Scholar2. Cushing H: Blood pressure reaction of acute cerebral compression, Am. J. M. Sc. 125: 1017, 1903. CrossrefGoogle Scholar3. RussellSargent HEP: Apoplectiform cerebral hemorrhage: operation: evacuation of blood: slow improvement, Proc. Roy. Soc. Med. (Sect. Neurol.) 2: 44, 1909. Google Scholar4. Bagley C: Spontaneous cerebral hematomas: discussion of four types with surgical consideration, Arch. Neurol. and Psychiat. 27: 1133 (May) 1932. CrossrefGoogle Scholar5. Penfield W: The operative treatment of spontaneous intracerebral hemorrhage, Canad. M. A. J. 28: 369, 1933. MedlineGoogle Scholar6. CraigAdson WMAW: Spontaneous intracerebral hemorrhage: etiology and surgical treatment, Arch. Neurol. and Psychiat. 35: 701 (April) 1936. CrossrefGoogle Scholar7. FurlowCarrWattenberg LTADC: Spontaneous cerebral hemorrhage: the surgical treatment of selected cases, Surgery 9: 758, 1941. Google Scholar8. Pilcher C: Subcortical hematoma, Arch. Neurol. and Psychiat. 46: 416 (Sept.) 1941. CrossrefGoogle Scholar9. Hamby WR: Gross intracerebral hematomas, New York State J. Med. 45: 866, 1945. Google Scholar10. RowbothamOgilvie GEAG: Chronic intracerebral haematomata: their pathology, diagnosis and treatment, British M. J. 1: 146, 1945. CrossrefMedlineGoogle Scholar11. Scott M: Surgical treatment of spontaneous non-traumatic hematomas, J. A. M. A. 130: 845, 1946. CrossrefMedlineGoogle Scholar12. GrossWechsler SWIS: Arteriography in cerebral vascular accidents, J. A. M. A. 39: 502, 1949. Google Scholar13. Sirois J: Surgical treatment of cerebral hemorrhage, Laval méd. 15: 457-466 (April) 1950. MedlineGoogle Scholar14. GrantAustin FCGM: The surgical treatment of spontaneous and traumatic intracerebral hemorrhage, Am. J. M. Sc. 219: 237, 1950. CrossrefMedlineGoogle Scholar15. Ferey D: The surgical therapy of spontaneous cerebral hemorrhage, Concours Med. 72: 1235-1236 (April) 1950. MedlineGoogle Scholar16. LusignanCross FWGO: Intracranial angiography in treatment of cerebrovascular accidents, California Med. 73: 240, 1950. MedlineGoogle Scholar17. GurdjianWebster ESJE: Cerebrovascular accidents, Arch. Surg. 62: 724, 1951. CrossrefGoogle Scholar18. Zimmerman HJ: Cerebral apoplexy, New York State J. Med. 49: 2153, 1949. MedlineGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Philadelphia, Pennsylvania*Presented at the Thirty-third Annual Session of the American College of Physicians, Cleveland, Ohio, April 25, 1952. (Presented in part before the Section on Neurology, American Medical Association Convention, June, 1951.)From the Department of Neurosurgery, Temple University Hospital and Medical School, and the Jewish Hospital, Philadelphia, Pennsylvania. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byBibliographyDiagnosis and Treatment of Facial Pain 1 October 1952Volume 37, Issue 4Page: 751-754KeywordsHemorrhageHemorrhagic strokeMortalityNeurologyNeurosurgeryStroke ePublished: 1 December 2008 Issue Published: 1 October 1952 PDF downloadLoading ...

An 11-week-old male infant presented with intracerebral hemorrhage associated with coagulopathy manifesting as left hemiparesis, lethargy, and vomiting. Computed tomography demonstrated extensive right frontoparietal intracerebral hemorrhage extending into the ventricular system. Liver function tests revealed abnormal values of transaminases and bilirubin. Blood coagulation studies showed prolonged prothrombin time (PT) and activated partial thromboplastin time (APPT). PT and APTT immediately normalized after the administration of vitamin K and fresh frozen plasma. Right parietal craniotomy and evacuation of the hematoma were performed because of the deterioration in consciousness and left hemiparesis. No vascular abnormality was observed in the hematoma cavity. After surgery, he became alert and the left hemiparesis improved. There is a risk of intracerebral hemorrhage due to vitamin K deficiency even if prophylactic administration of vitamin K was given. Surgical treatment should be considered for the treatment of infantile spontaneous intracerebral hemorrhage, especially if neurological deterioration is present.

The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time. Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined.

Purpose— The aim of this statement is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. Methods— A formal literature search of Medline was performed through the end date of August 2006. The results of this search were complemented by additional articles on related issues known to the writing committee. Data were synthesized with the use of evidence tables. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 5 expert peer reviewers and by the members of the Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years’ time. Results— Evidence-based guidelines are presented for the diagnosis of intracerebral hemorrhage, the management of increased arterial blood pressure and intracranial pressure, the treatment of medical complications of intracerebral hemorrhage, and the prevention of recurrent intracerebral hemorrhage. Recent trials of recombinant factor VII to slow initial bleeding are discussed. Recommendations for various surgical approaches for treatment of spontaneous intracerebral hemorrhage are presented. Finally, withdrawal-of-care and end-of-life issues in patients with intracerebral hemorrhage are examined. (Stroke. 2007;38:2001-2023.)

The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH. Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3. Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04). Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.

Response

ObjectiveAn advantage of surgical treatment over conservative treatment of spontaneous intracerebral hemorrhage (ICH) is controversial. Recent reports suggest that contrast extravasations on CT angiography (CTA) might serve as a crucial predictor of hematoma expansion and mortality. The purpose of this study was aimed at investigating the efficacy of surgical treatment in patients with spot sign positive ICH.MethodsWe used our institutional medical data search system to identify all adult patients who admitted for treatment of ICH between January 1, 2007 and January 31, 2012. Patients were classified two groups into a surgical group (n=27) and a conservative treatment group (n=28). Admission criteria were the following: age 20-79 years, spontaneous supratentorial ICH, Glasgow Coma Score Ranging from 9 to 14, ICH volume ≥20 mL, and treatment within 24 hours.ResultsFifty-five patients were analyzed. There was no significant difference in the ICU stay between the conservative treatment group (7.36±3.66 days) and the surgical treatment group (6.93±2.20 days; p=0.950). There was a significant difference in the in-hospital stay between the conservative treatment group (13.93±8.87 days) and the surgical treatment group (20.33±6.37 days; p=0.001). Overall mortality at day 90 after ICH was 36.4%; this included 16 of 28 patients (57.1%) in the conservative group and 4 of 27 patients (14.8%) in the surgical group. In univariate analysis, there was a positive effect of the surgical treatment in reducing mortality at 90 days (p=0.002), Glasgow Outcome Scale (GOS) at 90-day (p=0.006), and modified Rankin Scale (mRS) at 90-day (p=0.023). In multivariate logistic analysis, there was a significant difference in mortality (odds ratio, 0.211; 95% confidence interval, 0.049-0.906; p=0.036) between the groups at 90-day follow-up. However, there was no significant difference in GOS (odds ratio, 0.371; 95% confidence interval, 0.031-4.446; p=0.434) and mRS (odds ratio, 1.041; 95% confidence interval, 0.086-12.637; p=0.975) between the groups at 90-day follow-up.ConclusionIn this study of surgical treatment of supratentorial ICH in patients with spot sign positive in CTA was associated with less mortality despite of long duration of in-hospital stay. We failed to show that clinical outcome benefit of surgical treatment compared with conservative treatment in patients with spot sign positive ICH.

Perihematomal Edema After Spontaneous Intracerebral Hemorrhage.

Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing.

Objective To evaluate the value of CT plus CTA in emergency surgical treatment of spontaneous intracerebral hemorrhage caused by brain arteriovenous malformations(AVM). Methods A total of 15 cases diagnosed with spontaneous intracerebral hemorrhage by emergent CT examination in the Second Affiliated Hospital of Wenzhou Medical University were retrospectively reviewed from May 2015 to June 2018, and subsequent emergent CTA examination was adopted to verify whether the patients had brain AVM that was responsible for the hemorrhage. After diagnosis, emergency surgical resection of the brain AVM and evacuation of hematoma were performed. Glasgow outcome score (GOS) was used to evaluated the outcome. A secondary DSA or CTA was performed from 2 weeks to 6 months post the operation. Results All 15 cases exanimated by emergent CT plus CTA were demonstrated to have brain AVM and intracranial hematoma. All the patients received emergency brain AVM resection and hematoma evacuation. The surgical finding during operation was in line with what was seen on emergent CT plus CTA, and all cases got total hematoma evacuation. Twelve cases received total brain AVM resection, and the other 3 cases received partial resection because the residual AVM foci existed in deep brain structures. After the operation, none had rebleeding at the surgical site. Follow-up DSA or CTA confirmed the 12 cases had total resection and the other 3 cases had partial resection. All patients were alive after the surgery and GOS scores during the follow-up time, from 2 weeks to 6 months after emergency surgery, were: 5 in 6 patients, 4 in 4 patients, 3 in 4 patients and 2 in 1 patient. Conclusions CT plus CTA can better show the relationship between vascular malformation, hematoma, and the adjacent anatomical structure, and therefore may contribute to intraoperative judgment and complete resection of vascular malformation. It is a practical imaging tool for the preoperative evaluation and emergency surgical treatment of spontaneous intracerebral hemorrhage caused by brain AVM. Key words: Intracranial arteriovenous malformations; Angiography; Spontaneous intracerebral hemorrhage

Background and purpose. The options for managing spontaneous intracerebral haemorrhage (ICH) include conservative treatment, surgical removal of the haematoma and minimally invasive treatment with clot aspiration and subsequent fibrinolytic therapy. The discussion over which treatment is best for ICH remains controversial and management of patients with spontaneous ICH continues to be a challenge. The purpose of this study is to investigate the feasibility and safety of frameless stereotactic aspiration and subsequent fibrinolytic therapy for the treatment of spontaneous ICH.Methods. Patients with spontaneous supratentorial ICH were treated by a frameless stereotactic aspiration using the YL-1 type of intracranial haematoma puncture needle, followed by subsequent fibrinolytic therapy with urokinase.Results. Forty-eight patients were enrolled in the study. The median age was 65 years (range, 40–79). The median initial Glasgow Coma Scale (GCS) was 10 (range 6–14). The mean initial haematoma volume was 56.5 cm3. Initial ICH volume was reduced by an average of 75% (range 50–90%). Ten patients (20.8%) died before hospital discharge. By the 3-month follow-up, another two patients had died, resulting in an overall mortality of 25.0%. For the primary end point, a good outcome (3-month GOS score >3) rate was noted in 41.7% of the patients. No intraoperative death was observed in this study. There were a total of 14 (29.2%) procedure-related complications, with an overall re-bleeding rate of 10.4%.Conclusions. Frameless stereotactic aspiration using the YL-1 type of intracranial haematoma puncture needle and subsequent fibrinolytic therapy for the treatment of spontaneous ICH is a simple and safe procedure with low re-bleeding rate and mortality.

Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Comparison with Standard Craniotomy Using Propensity-Matched Analysis

The surgical treatment of spontaneous intracerebral haemorrhage (SIH) is still a matter of controversy, although most Neurosurgeons agree that surgery is indicated in selected cases. The introduction of computer tomography (CT) permits a more accurate determination of the localization, size and expansion of an intracerebral haemorrhage. The aim of this study is to evaluate the results of surgical and conservative therapy in selected cases and to search for parameters that could help to predict the outcome and facilitate the decision between surgery and conservative therapy. Seventy-four patients treated following SIH during the years 1976-1980 were analyzed. The decision for surgical treatment was made on the basis of the patient's conditions and the findings in the CT scan. Thirty-nine patients with mainly medium-sized haemorrhages underwent surgery and 35 were conservatively treated. The mortality after three months was 5/39 (13%) in the surgical and 7/35 (20%) in the conservative group. The volume of haemorrhage was significantly larger in the patients who died and 9/10 patients with a haematoma volume above 80 ml died. Five of these 10 were operated and the other 5 not and surgery seemed to be of little benefit to this group. Dilatation of the contralateral ventricle is another indicator of a bad prognosis. Long-term follow-up investigation was carried out 4-38 months after the initial treatment. Total mortality was 19 out of 68 patients that could be reached for late follow-up. Eleven patients (29%) were fully recovered and 16 had minor neurological deficits. There was no difference in late results between the surgical and the conservative groups, but the patients in the surgical group were generally in a worse condition and had larger haemorrhages that the others. The fact that the total mortality in this material is lower than in other conservatively treated series favours surgery in selected cases of SIH. The use of CT gives valuable information as to the prognosis and especially the volume of haemorrhage seems to be a good prognostic factor.

To the Editor: Hemphill et al1 present an analysis of 161 patients carried out to determine a reliable grading score for the prediction of 30-day mortality in patients following a spontaneous intracerebral hemorrhage (ICH). Factors independently associated with 30-day mortality were Glasgow Coma Score, age >80 years, ICH volume, ICH of infratentorial position, and presence of intraventricular hemorrhage. A score based on these variables was assigned to each patient. All patients within their dataset with an ICH score of 0 survived, and all patients with a score of 5 (highest score assigned) died. Hemphill et al restricted the testing of the scoring system to the data that produced it. We were interested in whether this scoring system could be of similar predictive value in patients treated in our unit. From 1994 to date, all patients admitted following a spontaneous supratentorial ICH have been recorded on a prospective database and followed up to 6 months after ictus. Although we do not have specific mortality at 30 days, we have recorded outcome at neurosurgical discharge, which was on average 2 to 4 weeks after ictus. Up to August 1999, 440 …

Approximately 5% of hospitalized stroke patients have a clinically apparent deep vein thrombosis (DVT) and ≈2% will have a pulmonary embolus (PE) confirmed.1 However, prospective studies that systematically screen for DVT with, for example compression Doppler ultrasound or magnetic resonance imaging, identified DVT in up to 50% of patients.2 Some patients who are breathless because of aspiration pneumonia, chest infection, or heart failure may actually have had an undiagnosed pulmonary embolus. Autopsies often identify clinically unrecognized PEs that probably contributed to the patient’s death. Therefore, it seems sensible to offer patients prophylaxis against venous thromboembolism. However, a brief discussion with colleagues is likely to reveal wide variation in the approaches taken to prophylaxis. In our unit, we aim to treat all patients with ischemic stroke with aspirin within 48 hours, because this has been shown to improve long-term outcomes and probably also reduces the risk of venous thromboembolism to some extent.3 In addition, we …