Surgery for spontaneous intracerebral hemorrhage

Abstract

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products.Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients' crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Keywords: Glasgow outcome scale; Hypertensive intracerebral hemorrhage; Intracerebral hemorrhage; MISTIE; Neurosurgical procedures; STICH; Stroke.

Conflict of interest statement

The author declares that he has no competing interests.

Figures

Fig. 1

Mechanisms of secondary brain injury after ICH. MLS - midline shift; IVH - intraventricular hemorrhage

Fig. 2

Case 01 of open craniotomy for hematoma drainage. a Day 1—a large intraparenchymal hematoma centered on the putamen, right insular, and frontotemporal region, with extravasation into the subarachnoid space of the sylvian fissure and temporal fossa, measuring about 6.1 × 4.5 × 4.8 cm on its largest axes. b Day 2—Hematoma was surgically removed by open craniotomy. CT shows signs of surgical manipulation characterized by enlargement and densification of soft tissue planes with gaseous foci underlying the right parietotemporal craniotomy. There was reduction of the dimensions of the intraparenchymal hematoma. c Day 7—Follow-up CT scan 6 days after surgical drainage. d Day 21—Follow-up CT scan 21 days after surgical drainage. Patient was discharged home after this last CT scan with a modified Rankin scale 4 (able to walk with assistance)

Fig. 3

Case 02 of open craniotomy for hematoma drainage. a, b Day 1—Large hematoma in the left cerebral hemisphere leading to collapse of the left lateral ventricle with a midline shift of 12 mm, with a large left ventricular and third ventricle flooding, as well as diffuse effacement of cortical sulci of that hemisphere. c–e Day 2—Left frontoparietal craniotomy, with well-positioned bone fragment, aligned and fixed with metal clips. Reduction of the left frontal/frontotemporal intraparenchymal hematic content, with remnant hematic residues and air foci in this region. There was a significant reduction in the mass effect, with a decrease in lateral ventricular compression and a reduction in the midline shift. Bifrontal pneumocephalus causing shift and compressing the adjacent parenchyma. f–h Day 36—Resolution of residual hematic residues and pneumocephalus. Encephalomalacia in the left frontal/frontotemporal region. Despite the good surgical results, the patient remained in vegetative state

Fig. 4

Open craniotomy. Patient lies on an operating table and receives general anesthesia. The head is set in a three-pin skull fixation device attached to the operating table, in order to hold the head standing still. Once the anesthesia and positioning are established, skin is prepared, cleaned with an antiseptic solution, and incised typically behind the hairline. Then, both skin and muscles are dissected and lifted off the skull. Once the bone is exposed, burr holes are built in by a special drill. The burr holes are made to permit the entrance of the craniotome. The craniotomy flap is lifted and removed, uncovering the dura mater. The bone flap is stored to be replaced at the end of the procedure. The dura mater is then opened to expose the brain parenchyma. Surgical retractors are used to open a passage to assess the hematoma. After the hematoma is drained, the retractors are removed, the dura mater is closed, and the bone flap is positioned, aligned, and fixed with metal clips. Finally, the skin is sutured

Fig. 5

Surgical trajectories of catheter insertion in minimally invasive surgery. This figure was adapted from previously published images by Fam et al. [49]. a Basal ganglia hemorrhage (caudate, putamen, or anterior capsule). The catheter is inserted through the forehead. Catheter trajectory: along the clot longitudinal axis. b Thalamic or posterior capsular hemorrhage. The catheter is inserted through the parietal-occipital area. Catheter trajectory: along the clot longitudinal axis. c Lobar hemorrhage. The catheter is inserted through the superficial area contiguous to the clot. Catheter trajectory: along the clot widest axis