Supratentorial Hematoma Research Articles

Challenges and Outcome after Surgery of Spontaneous Supratentorial Haematoma

Challenges and Outcome after Surgery of Spontaneous Supratentorial Haematoma

Portable ultrasound-guided keyhole evacuation of intracerebral hemorrhage: a detailed case report highlighting technical nuances.

Intracerebral hemorrhage (ICH) is a common neurosurgical emergency that is associated with high morbidity and mortality. Minimally invasive or endoscopic hematoma evacuation has emerged in recent years as a viable alternative to conventional large craniotomies. However, accurate trajectory planning and placement of the tubular retractor remains a challenge. We describe a novel technique for handheld portable ultrasound-guided minimally invasive endoscopic evacuation of supratentorial hematomas. A 64-year-old male diagnosed right hematoma (48.5 mL) at the basal ganglia was treated with emergent ultrasound-guided endoscopic transtubular evacuation through a small craniotomy. Ultrasound-guidance facilitated optimal placement of the tubular retractor into the long axis of the hematoma, and allowed for near-total evacuation, reducing iatrogenic tissue damage by mitigating the need for wanding or repositioning of the retractor. The emergence of a new generation of small portable phased array ultrasound probes with improved resolution and clarity has broadened ultrasound's clinical applications.

Uncertainty-aware deep-learning model for prediction of supratentorial hematoma expansion from admission non-contrast head computed tomography scan

Hematoma expansion (HE) is a modifiable risk factor and a potential treatment target in patients with intracerebral hemorrhage (ICH). We aimed to train and validate deep-learning models for high-confidence prediction of supratentorial ICH expansion, based on admission non-contrast head Computed Tomography (CT). Applying Monte Carlo dropout and entropy of deep-learning model predictions, we estimated the model uncertainty and identified patients at high risk of HE with high confidence. Using the receiver operating characteristics area under the curve (AUC), we compared the deep-learning model prediction performance with multivariable models based on visual markers of HE determined by expert reviewers. We randomly split a multicentric dataset of patients (4-to-1) into training/cross-validation (n = 634) versus test (n = 159) cohorts. We trained and tested separate models for prediction of ≥6 mL and ≥3 mL ICH expansion. The deep-learning models achieved an AUC = 0.81 for high-confidence prediction of HE≥6 mL and AUC = 0.80 for prediction of HE≥3 mL, which were higher than visual maker models AUC = 0.69 for HE≥6 mL (p = 0.036) and AUC = 0.68 for HE≥3 mL (p = 0.043). Our results show that fully automated deep-learning models can identify patients at risk of supratentorial ICH expansion based on admission non-contrast head CT, with high confidence, and more accurately than benchmark visual markers.

Mesenchymal Stem Cell Therapy in Acute Intracerebral Hemorrhage: A Dose-Escalation Safety and Tolerability Trial

BackgroundWe conducted a preliminary phase I, dose-escalating, safety, and tolerability trial in the population of patients with acute intracerebral hemorrhage (ICH) by using human allogeneic bone marrow–derived mesenchymal stem/stromal cells.MethodsEligibility criteria included nontraumatic supratentorial hematoma less than 60 mL and Glasgow Coma Scale score greater than 5. All patients were monitored in the neurosciences intensive care unit for safety and tolerability of mesenchymal stem/stromal cell infusion and adverse events. We also explored the use of cytokines as biomarkers to assess responsiveness to the cell therapy. We screened 140 patients, enrolling 9 who met eligibility criteria into three dose groups: 0.5 million cells/kg, 1 million cells/kg, and 2 million cells/kg.ResultsIntravenous administration of allogeneic bone marrow–derived mesenchymal stem/stromal cells to treat patients with acute ICH is feasible and safe.ConclusionsFuture larger randomized, placebo-controlled ICH studies are necessary to validate this study and establish the effectiveness of this therapeutic approach in the treatment of patients with ICH.

Clinical and neurophysiological correlations in patients with acute non-traumatic hemispheric hematomas

The aim of the study was to identify the relationship between clinical and neurophysiological parameters in patients with non-traumatic supratentorial hematomas. We examined 90 patients in acute period of parenchymal hemorrhagic stroke; the Glasgow Coma Scale (at first day) and the NIHSS (at 1st, 3rd, and 14th days) were used for the assessment of clinical dynamics. Two groups of patients were identified by means of cluster analysis. Cluster 1 included the patients with lower number of correlations between neurophysiologic parameters; cluster 2 included the patients with higher level of conjugacy in the mechanisms of nervous regulation. The clinical and neurophysiological correlations that differed between the groups of the patients were found. The role of EEG slow-wave activity and its association with the severity of neurological symptoms in the group of the patients with regress of neurological deficit were described. The role of desynchronizing influences in minimizing the severity of neurological deficit in patients with unfavorable course of disease was established. In conclusion, we emphasize the heterogeneity of the groups of the patients with parenchymal hemorrhagic stroke due to their clinical course; the role of synchronizing and desynchronizing influences of the brainstem structures according to EEG data in the assessment of the course of acute period of hemorrhagic stroke is highlighted.

Surgical Technique for Draining a Concomitant Supra-and Infratentorial Epidural Hematomas.

To assess clinical and radiological characteristics of simultaneous acute supra- and infratentorial epidural hematomas. We retrospectively reviewed the clinical and radiological data of 18 patients with a concomitant acute supra- and infratentorial epidural hematoma, who were treated and followed up at our hospital. The Glasgow Coma Score was 3-8 in four patients, was 9-12 in seven, and was 13-15 in seven patients. While the concomitant supra- and infratentorial hematoma did not cross the midline in 15 of the patients, it did in three of them. The dural venous sinus rupture was repaired in five of the patients. Functional healing was observed in 14 of the 18 patients. Two of the patients died during the postoperative period. A simultaneous supra- and infratentorial epidural hematoma rarely occurs in neurosurgical practice. Mortality and morbidity rates are high if these are not addressed in time. The radiological images of patients should be evaluated carefully preoperatively. In patients with a concomitant infra- and supratentorial hematoma, transverse sinus damage, which is a surgical challenge, should be considered. Herein, we describe a surgical technique (supra- and infratentorial craniotomy leaving the bone bridge over the transverse sinus) for draining a concomitant supra- and infratentorial epidural hematoma; this technique is an effective surgical choice in select patients.

Study of Intracranial Hematoma Removal and High Intracranial Pressure Reduction Using a Novel Three-Needle Brain Puncture Technique.

The present study aimed to evaluate the clinical value of minimally invasive surgery for intracranial hematoma removal and high intracranial pressure (ICP) reduction using a novel three-needle brain puncture technique. A total of 202 cases with supratentorial hematoma were analyzed, 54 of whom received three-needle brain puncture (study group), and the remaining cases received single-needle (control groups 1 and 2) and two-needle brain puncture (control group 3). The amount of intracranial hematoma removed, changes in ICP, retention time of puncture needle, volume of residual blood, the National Institute of Health Stroke Scale (NIHSS) score, and postoperative survival rate were used as indexes to evaluate patient outcomes. We found that three-needle brain puncture (study group) can remove more intracranial hematoma (P < 0.05) and achieve lower ICP (P < 0.05) than single- and two-needle brain puncture (control group). The needle retention time and volume of residual blood significantly decreased in the study group. Additionally, a statistically significant difference was observed in the NIHSS scores and survival rates between the study and control groups (P < 0.05). These data suggest that three-needle minimally invasive stereotactic puncture can effectively remove hematoma, reduce ICP, decrease the degree of brain damage, and improve prognosis.

Stereotactic IntraCerebral Underwater Blood Aspiration (SCUBA) Improves Survival Following Intracerebral Hemorrhage as Compared with Predicted Mortality

Recent publications on minimally invasive surgery (MIS) for hematoma evacuation have suggested survival benefits in select patients. Since 2015, our center has been performing an MIS technique using continuous irrigation with aspiration through an endoscope (stereotactic intracerebral underwater blood aspiration [SCUBA]). It is unknown how these patient outcomes compare with intracerebral hemorrhage (ICH) score predictions. Our aim is to determine if SCUBA patients had better 30-day mortality than predicted by their presenting ICH score. Retrospective review of consecutively admitted patients who underwent SCUBA between December 2015 and March 2019. Operative criteria for MIS evacuation included supratentorial hematoma volume ≥15 mL, age >18, National Institutes of Health Stroke Scale score ≥6, and modified Rankin Scale (mRS) score ≤3. Demographic, radiographic, and clinical data were collected prospectively. The prespecified primary outcome was observed 30-day mortality of SCUBA patients compared with predicted mortality by ICH score on presentation. One-hundred and fifteen patients underwent SCUBA for hematoma evacuation. Initial mean ICH volume was 51.4 mL (standard deviation 33.9 mL), with a median National Institutes of Health Stroke Scale score of 17 and ICH score of 2. At 1 month, 12 of the 115 SCUBA patients had passed away (30-day mortality rate 10.4%). This was significantly lower than the predicted mortality of 35.1% when calculated using the presenting ICH score (χ2 (1, N= 115)= 9.5, P < 0.0001), equating to an absolute risk reduction of 24.7%. This study suggests that minimally invasive hematoma evacuation with the SCUBA technique for ICH may reduce predicted 30-day mortality, with a number needed to treat of 4 to prevent 1 mortality.

The Patterns of Morphological Change During Intracerebral Hemorrhage Expansion: A Multicenter Retrospective Cohort Study.

Objectives: Hemorrhage expansion (HE) is a common and serious condition in patients with intracerebral hemorrhage (ICH). In contrast to the volume changes, little is known about the morphological changes that occur during HE. We developed a novel method to explore the patterns of morphological change and investigate the clinical significance of this change in ICH patients.Methods: The morphological changes in the hematomas of ICH patients with available paired non-contrast CT data were described in quantitative terms, including the diameters of each hematoma in three dimensions, the longitudinal axis type, the surface regularity (SR) index, the length and direction changes of the diameters, and the distance and direction of movement of the center of the hematoma. The patterns were explored by descriptive analysis and difference analysis in subgroups. We also established a prognostic nomogram model for poor outcomes in ICH patients using both morphological changes and clinical parameters.Results: A total of 1,094 eligible patients from four medical centers met the inclusion criteria. In 266 (24.3%) cases, the hematomas enlarged; the median absolute increase in volume was 14.0 [interquartile range (IQR), 17.9] mL. The initial hematomas tended to have a more irregular shape, reflected by a larger surface regularity index, than the developed hematomas. In subtentorial and deep supratentorial hematomas, the center moved in the direction of gravity. The distance of center movement and the length changes of the diameters were small, with median values of less than 4 mm. The most common longitudinal axis type was anterior–posterior (64.7%), and the axis type did not change between initial and repeat imaging in most patients (95.2%). A prognostic nomogram model including lateral expansion, a parameter of morphological change, showed good performance in predicting poor clinical outcomes in ICH patients.Conclusions: The present study provides a morphological perspective on HE using a novel automatic approach. We identified certain patterns of morphological change in HE, and we believe that some morphological change parameters could help physicians predict the prognosis of ICH patients.

Correlation between arteriovenous malformation nidus size and intraparenchymal hematoma volume in the event of rupture

•Our study did not support the hypothesis that small AVMs lead to larger hematoma volumes in the event of a rupture.•AVM size did not correlate with the clinical severity of the bleeding as measured with HH and WFNS scores.•Larger supratentorial hematomas were associated with a more severe clinical manifestation and a poorer outcome.•In the event of a rupture, the AVM size did not correlate with the 2-4-month GOS.•AVICH score showed a good correlation with the 2-4-month GOS score.

Clinico-radiological related to early brain death factors

ObjectiveTo identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 h. DesignA retrospective cohort study was made covering the period 2015−2017. SettingAn adult Intensive Care Unit (ICU). Patients/methodsEpidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. ResultsA total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD > 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD > 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD > 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups. ConclusionsEarly BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Surgery of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance

Background. Hypertensive intracranial hemorrhage is an extremely serious complication of hypertension, which accounts for 10 % to 20 % of all cerebral strokes. About 50 % patients die within the next year, and their 5-year survival rate does not exceed 30 %. Objective. To study the effectiveness of surgical treatment of hypertensive intracranial hematomas using one-portal mini-access and video endoscopic assistance. Design and methods. The study included 23 patients with supratentorial intracerebral hypertensive hematomas aged 26 to 70 years (median age 55 (50; 61) years). All patients underwent one-portal endoscopic surgery. The median volume of intracerebral hematoma, calculated according to the Tada formula, was 50 (40; 60) ml. The comparison group included 28 patients who received conservative treatment. The dynamics of the severity was assessed using the Glasgow Coma Scale (GCS), NIHSS, Rankin, Rivermead scales upon admission to the hospital, on days 3 and 7 of treatment, at discharge for outpatient treatment, and after 6 months.Results. There were no lethal outcomes in either the main group or the comparison group. The hematoma was removed totally in all patients, which was accompanied by a rapid improvement of general cerebral symptoms and, as a consequence, an increase in GCS values from 13 (12; 14) to 13 (12; 15) points by 3rd day after the disease onset. By the 7th day, there was a slow positive dynamic in both groups, however, all patients still had a pronounced or severe disability according to the Rankin scale. After 6 months, patients who underwent surgical treatment showed faster and more complete recovery. Conclusions. The results of the study are consistent with current worldwide data on the effectiveness of modern endoscopic technologies in patients with hypertensive intracerebral hemorrhage in relation to the rate and degree of regression of neurological loss.

Impact of Increased Hemoglobin on Spontaneous Intracerebral Hemorrhage

BackgroundStudies of the impact of increased hemoglobin on spontaneous intracerebral hemorrhage (ICH) are limited. The present study aimed to explore the effect of increased hemoglobin on ICH.MethodsA retrospective single-center study using medical records from a database processed by univariate and multivariate analyses was performed in the People’s Hospital of Tibet Autonomous Region in Lhasa, Tibet, China.ResultsThe mean hemoglobin level in 211 patients with ICH was 165.03 ± 34.12 g/l, and a median hematoma volume was 18.5 ml. Eighty-eight (41.7%) patients had large hematomas (supratentorial hematoma ≥ 30 ml; infratentorial hematoma ≥ 10 ml). No differences in ICH risk factors between the groups with different hemoglobin levels were detected. Increased hemoglobin was independently associated with large hematomas [odds ratio (OR) 1.013, P = 0.023]. Increased hemoglobin was independently associated with ICH with subarachnoid hemorrhage (OR 1.014, P = 0.016), which was more pronounced in men (OR 1.027, P = 0.002). Increased hemoglobin was independently associated with basal ganglia hemorrhage and lobar hemorrhage in men (OR 0.986, P = 0.022; OR 1.013, P = 0.044, respectively) but not in women (P > 0.1).ConclusionsIncreased hemoglobin was independently associated with large hemorrhage volume. Increased hemoglobin was independently associated with lobar hemorrhage in men and ICH with subarachnoid hemorrhage, which was more pronounced in men. Additional studies are needed to confirm our findings and explore potential mechanisms.

Use of the Image Guided Minimally Invasive BrainPath System to Evacuate Spontaneous Cerebellar Hemorrhages.

BrainPath (NICO, Indianapolis, Indiana) is a tool that can be used to evacuate supratentorial hematomas due to spontaneous intracerebral hemorrhage (ICH). However, when ICH occurs in the posterior fossa, an open approach is often undertaken to evacuate the hematoma. The application of minimally invasive technology, while available, has not been well established. Our objective was to describe the use of the image-guided, minimally invasive BrainPath system to evacuate a spontaneous cerebellar hemorrhage. We present the case of a sixty-four-year-old male patient with a cerebellar hematoma due to hypertensive hemorrhage. The patient's medical record, including the history and physical, progress notes, operative notes, discharge summary, and imaging studies were reviewed to document the clinical presentation as well as the details of the operative technique and postoperative outcomes in this paper. We discuss the technical nuances of the operative points in detail. In our example case, the BrainPath system was successfully used to evacuate the cerebellar hematoma and no procedural-related complications occurred. The patient's recovery remained uncomplicated at three months of follow-up. In summary, the BrainPath system offers a less invasive alternative to open evacuation for cerebellar bleeds.

Decompressive craniectomy in the treatment of supratentorial hypertensive intracerebral hematomas

The study objective is to evaluate feasibility and effectiveness of decompressive craniectomy (DC) for treatment оf supratentorial hypertensive intracerebral hematomas (ICH).Materials and methods. Between 1996 to 2019, 97 patients with supratentorial hypertensive ICHs underwent surgical treatment. DC was performed in 50 patients (primary - in 41, secondary - in 9). Putaminal hematomas were diagnosed in 30 patients, subcortical - in 20. The comparison group consisted of 47 patients, of which 20 had osteoplastic craniotomy (OPC) with microsurgical removal of ICH, and 27 had endoscopic aspiration (EA). The performed DCa were treated as unjustified (decreased brain dislocation without prolapse of the brain substance into the trepanation defect), ineffective (preservation of brain dislocation and absence of prolapse of the brain substance into the trepanation defect, as well as small size of the trepanation hole) and effective (prolapse of the brain substance into the trepanation defect and regression of transverse brain dislocation).Results. DC was effective only in 22 (44 %) patients (13 - primary, 9 - secondary). Among patients with subcortical ICH, mortality rate after DC was equal to that after OPC and EA. Among patients with putaminal ICH, the mortality rate after DC was significantly higher than after OPC and EA. Among the patients who underwent primary EA and delayed DC (due to recurrent ICH), postoperative mortality rate was significantly higher than among the patients who underwent repeated EA of recurrent ICH. However, there were no fatal outcomes among patients who underwent delayed DC due to increased edema and transverse dislocation of the brain without recurrent ICH.Conclusion. In the surgical treatment of supratentorial hypertensive ICH, decompressive effect of DC was achieved only in 44 % of patients. Open removal of putaminal hematomas in combination with DC was unjustified, mortality rate was 66 %. Primary DC with removal of ICH is indicated in patients with subcortical hematomas with a volume &gt;50 cm3 , with transverse dislocation &gt;7 mm, deep deafness or sopor. Delayed DC, regardless of the location of ICH, is recommended in case of increased edema and transverse dislocation of the brain in patients without recurrent hemorrhage.

Insights in the pathophysiology of haemorrhagic strokes in a sub-Sahara African country, an epidemiological and MRI study.

Intra-cerebral Haemorrhage (ICH) seems more prevalent in sub-Saharan Africa (SSA) than in High-Income Countries (HIC) with poorer clinical outcome. Higher impact of hypertension and/or amyloid angiopathy could account for this disproportion. Here, we sought to (i) retrospectively compare ICH clinical and imaging patterns in Belgium and Guinea and in a subsequent cohort (ii) prospectively compare brain MRI characteristics to seek evidence for a different proportion of amyloid angiopathy patterns. Ninety one consecutive patients admitted for spontaneous ICH at Brussels Erasme-ULB Hospital and at Conakry Ignace Deen-UGANC were retrospectively compared in terms of ICH volume estimated with the ABC/2 method, clinical characteristics and modified ranking (mRS) score at 30days. mRS was dichotomised as good outcomes (≤3) and poor outcomes (>3). A prospective cohort of 30 consecutive patients with ICH admitted at CHU Conakry Ignace Deen-UGANC was prospectively included to undergo brain MRI. Results of the Guinean MRI were compared to 30 patients randomly selected from Brussels' initial cohort. Paired Student's t-test and Mann-Whitney u-test were used for group comparisons. Age of ICH onset was higher in Belgium (68±17years vs. 56±14years, P<0.01) while ICH volume and 30-day mortality rate were higher in Guinea (20ml vs. 11ml, P<0.01 and mortality 33% vs. 10 %, P<0.01). ICH burden in survivors in Conakry and Brussels showed respectively good outcomes in 56.7% and 60.4% (P=0.09) and poor outcomes in 10.3% vs. 29.6% (P<0.001). MRI analysis of the prospective cohort failed to disclose significant differences regarding brain MRI characteristics. Intra-cerebral Haemorrhage affected patients 15years younger in Guinea with larger haematoma volumes and higher mortality than in Belgium. MRI findings did not show more prevalent amyloid angiopathy pathology suggesting that better primary prevention of hypertension could positively impact ICH epidemiology in Guinea.

Clinico-radiological related to early brain death factors.

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24hours. A retrospective cohort study was made covering the period 2015-2017. An adult Intensive Care Unit (ICU). Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD. A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24h (p=0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9ml in early BD versus 82.7ml in BD>24h (p=0.54). The mean midline shift was 10.7mm in early BD versus 7.8mm in BD>24h (p=0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p=0.021). Thirty-six patients with early BD versus 24 with BD>24h presented complete effacement of basal cisterns (p=0.005), sulcular effacement (p=0.013), loss of cortico-subcortical differentiation (p=0.0001) and effacement of the suprasellar cistern (p=0.005). The optic nerve sheath measurements showed no significant differences between groups. Early BD (>24h) was associated to GCS<5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

The Effect of Telemedicine Consultation on Outcomes in Patients with Intracerebral Hemorrhage

RELEVANCE. Telemedicine solves the problem of the availability of highly qualified personnel at the decision-making stage in the management of patients with intracerebral hemorrhage. AIM OF STuDY We set out to evaluate the effect of teleconsultation on outcomes in patients with intracerebral hemorrhage 30 days after the event.MATERIAL AND METHODS. A prospective, open, nonrandomized clinical trial in two parallel groups. The first group included adult patients up to 80 years of age with a hemorrhagic stroke from 4 to 36 points according to NIHSS due to unilateral supratentorial intracerebral hematoma of non-aneurysmal genesis, who were examined by a neurosurgeon and resuscitator of the Regional Vascular Center in a ward. The second group included similar patients, but they received telemedicine consultation of the above specialists. The primary endpoint of the study was mortality 30 days after the onset of the stroke. The hypothesis of non-superiority was tested where the 95% confidence interval (CI) for the difference in mortality between the groups should not go over 15 percentage points.RESULTS. A total of 140 patients (70 in each group) with intracerebral hematomas were studied. Mortality in the bedside group was 14.3% (CI 7.1%; 24.7%), and in the remote group it was 25.7% (16.0%; 37.6%), p=0.091. However, there was no evidence of superiority, since the difference between the groups in mortality was 11.4 with CI from –0.07 to 24.5 percentage points, which was beyond the predefined limit.CONCLUSIONS. At the current level of development of medicine and information technology, telemedicine cannot fully replace the traditional (bedside) consultation of an expert level of neurosurgeon and neuroresuscitator in patients with intracerebral hematomas.Authors declare lack of the conflicts of interests.

The Functional Outcome of Spontaneous Hypertensive Supratentorial Intracerebral Haemorrhage after Surgery

This study was to determine the different parameters that affect the outcome and the functional recovery after surgical evacuation of spontaneous hypertensive supratentorial intracerebral haemorrhage. This cross-sectional analytic study was conducted in the Department of Neuro- surgery, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh during a period of 4 years from January 2016 to December 2019 and total 96 patients were included in this study. Patients with post-traumatic hematomas, intracranial space-occupying lesions with bleeds, haemorrhagic transformation of an ischemic stroke, vascular malformations, aneurysms, and infratentorial haemorrhages were excluded from the study. Decompressive craniotomy and evacuation of clot was performed in most of the cases. The outcome of the patients was categorized according to the Glasgow Outcome Scale. Outcome was classified as “favourable” if the Glasgow Outcome Scale (GOS) score was 5 or 4, and classified as “unfavorable” if GOS score was 3 or less. The mean age of the patients was 57.99±12.74 years with male and female ratio was 1.66. The mean blood volume was 28±19.99 cc and all patients were hypertensive. There was significant difference (p &lt;0.001) in outcome in relation of age and volume of blood. Age &gt; 70 years, GCS &lt; 8 on admission, clot volume above 40 cc, and intraventricular extension remain the most consistent predictors of mortality and poor outcome following surgical evacuation of spontaneous supratentorial intracerebral hematoma. The present study could only assess mortality and the functional outcome. Since a proportion of survivors had an unfavorable outcome, quality of life measures is important and need to be addressed in future studies.

Surgery for spontaneous intracerebral hemorrhage – A comparative study with medical management in moderate to large sized hematomas

ObjectivesIntracerebral Hemorrhage (ICH) is a devastating form of stroke and accounts for 10–15% of all cases. The management of ICH has predominantly been directed towards medical management. Multiple trials have failed to prove the superiority of surgical evacuation over conservative methods. However, surgery in a carefully selected set of patients is beneficial in reducing mortality and limiting disability. In this article, we retrospectively analysed our ICH register to compare the outcomes of surgical and conservative management of patients <70 years having a clot volume above 30 ml. Patients and MethodsWe retrospectively analysed patients with ICH admitted at our centre between January 2015 and December 2017. A total of 119/624 patients with supratentorial hematoma volume >30 ml, GCS ≥ 5 and age less than 70 were included in this study. ResultsThe group was dichotomised into two groups A & B based on the management. Seventy-two (60.5%) patients underwent surgical intervention in group A and the remaining 47 (39.5%) were managed by best possible conservative methods in group B. The mean age in Group A was 51.01 years and 55.89 years in group B (P = 0.012). The volume of hematoma in the surgical group was 46.5 ± 14.9 ml in comparison to 38.53 ± 10.84 ml in the medically managed group (p = 0.002). Mortality at 90 days was 27/47 (57.44%) in the medically managed group while 23/72 (31.9%) in the surgical group (p = 0.006). Median mRS at discharge and 90 days were nearly identical and there was no significant difference in the dichotomized outcome among the two different management cohorts (p > 0.05). Mortality was the highest in the 30–50 ml medically managed group and >51 ml surgical group (p = 0.024). Age of the patient, GCS on presentation and medical management were independent predictors of mortality on logistic regression. The Cox Regression survival analysis of the two groups showed a clear survival advantage in the surgically managed group adjusting for age and GCS (p = 0.002) at 90 days. ConclusionSurgical Evacuation of spontaneous intracerebral haemorrhage has a survival advantage at 90 days in moderate to large sized hematomas. It, however, did not demonstrate any quantifiable improvement in functional outcome. Surgical evacuation of moderate-sized hematomas reduces mortality caused by delayed perihematomal oedema.