No abstract

Background and Purpose-Treatment of intracerebral hematoma (ICH) is controversial. An advantage of neurosurgical intervention over conservative treatment of ICH has not been established. Recent reports suggest a favorable effect of stereotactic blood clot removal after liquefaction by means of a plasminogen activator. The SICHPA trial was aimed at investigating the efficacy of this treatment. Methods-A stereotactically placed catheter was used to instill urokinase to liquefy and drain the ICH in 6-hour intervals over 48 hours. From 1996 to 1999, 13 centers entered 71 patients into the study. Patients were randomized into a surgical group (nϭ36) and a nonsurgical group (nϭ35). Admission criteria were the following: age Ͼ45 years, spontaneous supratentorial ICH, Glasgow Eye Motor score ranging from 2 to 10, ICH volume Ͼ10 cm 3 , and treatment within 72 hours. The primary end point was death at 6 months. As secondary end points, ICH volume reduction and overall outcome measured by the modified Rankin scale were chosen. The trial was prematurely stopped as a result of slow patient accrual. Results-Seventy patients were analyzed. Overall mortality at day 180 after stroke was 57%; this included 20 of 36 patients (56%) in the surgical group and 20 of 34 patients (59%) in the nonsurgical group. A significant ICH volume reduction was achieved by the intervention (10% to 20%, PϽ0.05). Logistic regression analysis indicated the possibility of efficacy for surgical treatment (odds ratio, 0.23; 95% confidence interval, 0.05 to 1.20; Pϭ0.08). The odds ratio of mortality combined with modified Rankin scale score 5 at 180 days was also not statistically significant (odds ratio, 0.52; 95% confidence interval, 1.2 to 2.3; Pϭ0.38). Conclusions-Stereotactic aspiration can be performed safely and in a relatively uniform manner; it leads to a modest reduction of 18 mL of hematoma reduction over 7 days when compared with control, which has a 7-mL reduction, and therefore may improve prognosis.

In a prospective study, the prognostic value of clinical characteristics in 157 consecutive patients with spontaneous supratentorial intracerebral haemorrhage were examined by means of multivariate analysis.Two days after the event 37 (24%) patients had died. Factors independently contributing to the prediction of two day mortality were pineal gland displacement on CT of 3 mm or more (p < 0-001), blood glucose level on admission of 8-0 mmolIl or more (p = 0-01), eye and motor score on the Glasgow Coma Scale of eight out of 10 or less (p = 0.022) and haematoma volume of 40 cm3 or more (p = 0.037).Between the third day and one year after the event another 46 of the 120 two day survivors had died; the independent prognostic indicators for death during that period were: age 70 years or more (p < 0-001) and severe handicap (Rankin grade five) on the third day (p < 0-001). Functional independence (Rankin grade two or less) at one year was most common not only with the converse features of age less than 70 years (p < 0-01) and Rankin grade four or less on the third day (p = 0.002), but also with an eye and motor score on the Glasgow Coma Scale of nine or 10 on the third day (p < 0.001).The 120 patients with intracerebral haemorrhage who were still alive two days after the event were matched with 120 patients with cerebral infarction, according to age, level of consciousness on the third day after stroke (Glasgow Coma Scale) and handicap (Rankin grade). Survival and handicap after one year did not differ between these two groups. The conclusion drawn is that it is not the cause (intracerebral haemorrhage or cerebral infarction) but the extent of the brain lesion that determines the outcome in patients who survive the first two days. (7 Neurol Neurosurg Psychiatry 1992;55:653-657)

Patients who recovered from a primary intracerebral hemorrhage had a 2.1% to 5.9% annual rate of recurrence, vascular death, or vascular events. Age of 65 years or older more than doubled the risk of recurrence, vascular event, or death. The risk of vascular events in men was increased twofold.

We retrospectively studied 79 patients from three centers who suffered an intracerebral hemorrhage during treatment with anticoagulants and compared them with 84 patients from one center who suffered a spontaneous intracerebral hemorrhage without anticoagulant treatment Mortality after 30 days was slightly higher in patients with anticoagulant treatment (67%) than in those without (55%), and the proportion of patients who attained moderate or complete recovery was slightly smaller in the treated group (22% and 36%, respectively); neither difference was statistically significant. Volume of the supratentorial hematoma was measured from computed tomograms in 70% of the patients in both groups and was significantly greater in the 55 patients treated with anticoagulants than in the 59 patients not so treated. Volume was not related to the degree of anticoagulation. Based on the total number of patients treated with anticoagulants in the Heerlen region, we conclude that for patients older than 50 years of age the risk of intracerebral hemorrhage during anticoagulant treatment is increased approximately eightfold but is unrelated to the degree of anticoagulation. Our results suggest that intracerebral hemorrhage is more frequent and more extensive in patients treated with anticoagulants but that once it has occurred in such patients intracerebral hemorrhage is not significantly more serious than in untreated patients. (Stroke 1990;21:726-730) T he occurrence of intracerebral hemorrhage (ICH) in patients treated with anticoagulants is a serious complication, often fatal. The risk of ICH in patients >50 years of age who have been treated with anticoagulants is estimated to be 10 times that in untreated subjects of the same age.1 In that study, outcome in treated patients was not different from that in untreated patients, but ICH was diagnosed mainly on clinical grounds. Additionally, it is uncertain whether the risk of ICH is related to the duration and degree of anticoagulation. According to some studies the risk is greatest during the first 6 months, 2 whereas other workers have found that most ICHs occur after at least 1 year of anticoagulation.1 Though ICH in patients receiving anticoagulants often results from overtreatment, many authors have reported a therapeutic degree of anticoagulation at the moment of the bleeding. Received June 23, 1989; accepted January 9, 1990. has not yet been studied in relation to the use of anticoagulants.The purpose of our retrospective study, which we believe is the largest of its type, was to examine the influence of anticoagulation treatment on the risk of ICH, the volume of the hematoma, and the clinical course compared with patients suffering an ICH who were not treated with anticoagulants.