Abstract
Hemorrhage in the central nervous system (CNS), including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH), remains highly morbid. Trials of medical management for these conditions over recent decades have been largely unsuccessful in improving outcome and reducing mortality. Beyond its role in creating mass effect, the presence of extravasated blood in patients with CNS hemorrhage is generally overlooked. Since trials of surgical intervention to remove CNS hemorrhage have been generally unsuccessful, the potent neurotoxicity of blood is generally viewed as a basic scientific curiosity rather than a clinically meaningful factor. In this review, we evaluate the direct role of blood as a neurotoxin and its subsequent clinical relevance. We first describe the molecular mechanisms of blood neurotoxicity. We then evaluate the clinical literature that directly relates to the evacuation of CNS hemorrhage. We posit that the efficacy of clot removal is a critical factor in outcome following surgical intervention. Future interventions for CNS hemorrhage should be guided by the principle that blood is exquisitely toxic to the brain.
Highlights
Acute central nervous system (CNS) hemorrhage, including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), subdural hematoma (SDH), and traumatic contusion, comprises a large portion of the modern neurosurgical case load.While neurosurgical techniques have greatly expanded in recent decades, these diseases still leave most patients dead or highly dependent.1.1
Consistent with the concept that blood is toxic to the brain and that it should be the primary target of any ICH intervention, decompressive craniectomy (DC) alone has not been shown to improve functional outcomes
A small retrospective series comparing ICH evacuation with quantified Hematoma evacuation efficacy (HEE) (92% average evacuation) vs. ICH evacuation + DC found no benefit for the addition of DC in terms of functional outcome, suggesting near-complete hematoma evacuation alone is sufficient for treatment of ICH
Summary
Acute CNS hemorrhage, including intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), subdural hematoma (SDH), and traumatic contusion, comprises a large portion of the modern neurosurgical case load. While neurosurgical techniques have greatly expanded in recent decades, these diseases still leave most patients dead or highly dependent
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