Management of
Spontaneous Intracerebral
Haematomas - a Neurosurgeons Perspective by DR. vineet
saggar Consultant neurosurgeon (Brain & Spine Specialist) ivy hospital
Chandigarh mohali
Spontaneous
intracerebral hemorrhage (ICH) accounts for 9% to 25% of all strokes and
has devastating consequences.
More than
50% of patients die, and half of the survivors are left severely
disabled.
Death at
1 year varies by different location: 51% for deep, 57% for lobar, 42% for
cerebellar and 65% for brain stem hemorrhages
CAUSES
OF SPONTANEOUS ICH
Depending
on the underlying cause of hemorrhage, ICH may be classified as
Primary
when it originates from the spontaneous rupture of small arterioles damaged by
chronic hypertension or cerebral amyloid angiopathy, representing at least 85%
of all cases
or
secondary
when associated with
vascular
malformations,
Bleeding
related to an ischemic stroke,
tumors,
abnormal
coagulation or vasculitis
Pathophysiology
Intracerebral
haemorrhage due to chronic hypertension accounts for about one-half of the
cases.
The
underlying pathology is haemodynamic injury to perforating arteries, 100—400
urn in diameter, which arise directly from much larger trunks to enter
the brain at right angles and are end arteries.
Whereas
the cortical vessels are protected by a thicker smooth muscle layer in
the media, a series of bifurcations and collateral vessels, the perforating
arteries are subjected directly to changes in blood pressure.
The arteries
in question include the lenticulostriate arteries, the thalamoperforating
arteries the paramedian branches of the basilar artery and the superior and
anterior inferior cerebellar arteries.
The pathological lesions may take the form of hyalinosis, lipohyalinosis or focal necrosis and
Charcot-Bouchard/miliary aneurysm formation
Locations of hypertensive ICH are as
follows:
65%
in the basal ganglia,
15%
in the subcortical white matter,
10%
cerebellar
10%
pontine
MANAGEMENT
It is
important to determine the underlying aetiology rapidly. A history of
hypertension, drug abuse and anticoagulant treatment is important.
If a
history of hypertension is not available, it may be difficult in the acute
state in a patient with high blood pressure to decide whether it is due to
previously undetected hypertension or secondary to raised intracranial pressure
(ICP) with a Cushing response.
Signs of
end organ damage (brain, retina, heart and kidneys) can help differentiate the
two.
DIAGNOSTIC MODALITIES
CT is the
investigation of choice
Advantages
CT scan
evaluates the size and location of the hematoma,
Extension
into ventricular system
Degree of
surrounding edema,
Anatomical
disruption (Class I, Level of Evidence A).
Hematoma
volume may be easily calculated from CT scan images by use of the following
formula
ABC÷2
a derived
formula from the calculation of the volume of the sphere.
Right Basal
Ganglia Haematoma With Intraventricular Extension in a Hypertensive
Role of Surgery : When to operate
1. A spectrum of ICH patients are alert
with subtle neurological signs and small (< 2 cm) haematomas
Surgery not indicated
2. Indications for surgery between 1 and 3 are
controversial The following patients are more likely to be operated upon (i)
clot volumes between 20-80 ml,(2)superficial lobar haemorrhages, and (3)
worsening conscious level/neurological deficit
3. Large haemorrhage with significant neuronal
destruction and poor neurological status (GCS < 5)Surgery not indicated.
Most neurosurgeons
would operate on patients with a deteriorating conscious level and a worsening neurological deficit
In addition, lobar/superficial haematomas 20—80 ml
in volume are more likely to be operated upon
Cerebellar haemorrhage greater than 3—4 cm should be
operated upon, especially when there is concomitant clinical deterioration or
hydrocephalus3
Stich 1 Trial
The need to gain robust evidence to support clinical
decision making led to the initiation of the Surgical Trial in Intracerebral
Haemorrhage (STICH) funded by the MRC and the Stroke Association in 1998.
STICH was a prospective randomised trial to compare
Early surgery
with
Initial conservative
treatment
in with spontaneous supratentorial intracerebral
haemorrhage.
A parallel group-trial design was used
Early surgery combined haematoma evacuation (within
24 hours of randomisation)
with
best medical
treatment.
Initial conservative treatment used best medical
treatment although delayed evacuation was allowed if it became necessary.
Analysis was on an intention-to-treat basis.
Primary Outcome Measure: 8 point Glasgow Outcome
Scale sent as a postal questionnaire to patients at 6 months follow-up. From
this a dichotomised prognosis-based outcome measure was used
Results: This trial was the largest to date and
successfully recruited 1033 patients from 87 centres around the world. Patients
were randomised to early surgery (503) or initial conservative treatment (530).
Of 468 patients randomised to early surgery 26% had a favourable outcome
compared to 24% of the 496 randomised to initial conservative treatment (95% CI
0.66-1.19, p=0.414). (Outcome data was unavailable for 69 patients).
Interpretation: STICH suggested a small
non-significant advantage for surgery
Although the STICH has rightfully dampened the
enthusiasm of neurosurgeons for performing surgery, it must be remembered that
the trial was based on the principle of clinical equipoise and patients who the
local investigator felt would most likely benefit from emergency surgery were
not enrolled into the study.
In a post hoc
analysis of the STICH it was found that
the subgroup of patients with superficial hematomas and no IVH
had better outcomes in the surgical arm
Where do we go from STICH 1 TRIAL
PATIENTS IN WHOM
SURGERY WAS DIRECTLY INDICATED SUCH AS LARGE LOBAR HAEMATOMAS OR CEREBELLAR
HAEMATOMAS WERTE NOT INCLUDED IN STUDY- THESE WERE THE PATIENTS WHO BENEFIT
MOST FROM SURGERY AND HENCE WOULD HAVE INCREASED % OF FAVOURABLE OUT IN SURGICAL ARM
2 ALSO PATIENTS WHO
DETERIORATED ON MEDICAL TREAT MENT WERE AGAIN OPERATED AND THEIR OUT COME WAS
NOT INCLUDED IN DATA FOR MEDICAL M/M THERE BY IMPROVING OUT COME IN MEDICAL T/T
GROUP
BECAUSE THESE ARE THE
PATIENTS WHO HAVE POORER OUTCOMES.
STICH-2
Disease/condition/study
domain Spontaneous intracerebral haemorrhage confined to the lobar region
Participants - inclusion criteria
Evidence of a spontaneous lobar ICH on Computed Tomography (CT) scan
(within 1 cm of the cortical surface)
Patient within 48 hours of ictus
The 'clinical uncertainty principle' is used: only patients for whom the
responsible neurosurgeon is uncertain about the benefits of either treatment
are eligible. These include patients with a haematoma volume of between 10 and
100 ml and a best motor score on the Glasgow Coma Score (GCS) of five or six
together with some eye opening
Participants - exclusion criteria
1 Clear evidence that the haemorrhage is due to an
aneurysm or angiographically proven arteriovenous malformation
2. Intraventricular haemorrhage of any sort
3. ICH secondary to tumour or trauma
4. Basal ganglia, thalamic, or brainstem haemorrhage or extension of a
lobar haemorrhage into any of these regions
5. Severe pre-existing physical or mental disability
or severe co-morbidity which might interfere with assessment of outcome
6. If surgery cannot be performed within 12
hours
Current practice favours surgical intervention in
the following situations:
superficial haemorrhage, >10 ml in volume
Clot volume between 20-80 ml; with worsening neurological
status; and relatively young patients;
(v) Haemorrhage causing midline shift/raised ICP;
and (vi) Cerebellar haematomas >3 cm or causing hydrocephalus.
Dr. Vineet Saggar
(MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
http://www.neurosurgeoninchandigarh.com
http://neurosergeonhead.blogspot.in
http://www.facebook.com/neuro.surgeon.7186
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
http://www.neurosurgeoninchandigarh.com
http://neurosergeonhead.blogspot.in
http://www.facebook.com/neuro.surgeon.7186
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