Surgical Strategies for Spontaneous Intracerebral Hemorrhage

Abstract

In recent decades, the medical and surgical treatment of intracerebral hemorrhage (ICH) have become the focus of a number of scientific investigations. This effort has been led by an international group of neurologists and neurosurgeons with the goal of studying functional recovery and developing new medical and surgical treatments to facilitate improved clinical outcomes. Currently, two of the most pressing ICH investigational goals are (1) early blood pressure control, and (2) safe hematoma volume reduction. Answering these questions would support decision-making, level-of-care choices, and the global research strategy of developing biologically informed treatments. The authors review the contemporary medical management and the conventional and minimally invasive surgical approaches to spontaneous ICH, as well as discuss the scope of the problem, recent clinical trials, management issues, and relevant questions for future research. They propose the hypothesis that strategies using minimally invasive techniques, including clot aspiration with stereotactic guidance, may give better results with improved clinical outcomes compared with standard open surgical approaches. They also discuss the level of evidence for the variously known approaches.

Bedside Catheter Hematoma Evacuation in Vitamin K Antagonist-Related Intracerebral Hemorrhage: A Safe and Feasible Approach

“…Thus, a rapid reduction in hematoma volume would theoretically represent the treatment of choice to improve outcome in ICH patients. However, clinical data from randomized controlled trials, as well as several meta-analyses (3-6), were not able to show any general advantages of craniotomy-related clot removal in ICH patients, compared to those receiving standard medical treatment (2). Most of the meta-analyses included studies that use different surgical techniques (i.e., conventional open surgery vs. minimally invasive approaches) in the intervention group for comparison to best medical treatment, thus limiting interpretation of the results.…”

“…An outcome-modifying treatment approach is yet to be established in ICH patients (2). Hematoma volume is a key prognostic factor for poor outcome (25), with two major pathophysiological mechanisms: first, the ICH leads to mechanical disruption of neurons and glia, where an additional volume-related, space-occupying effect can potentially lead to reduced cerebral blood perfusion, the compression of more distal brain parenchyma, or even herniation (1,2). Second, the presence of blood induces the activation of detrimental pathways that can subsequently lead to inflammation, peri-hemorrhagic edema, and, in turn, further neuronal damage (27,28).…”

“…Many attempts have been made at improving the poor functional outcome in intracerebral hemorrhage (ICH) patients. One of the major pathophysiological factors related to a poor outcome has been identified as increased hematoma volume, which either causes mechanical disruption or space-occupying mass effects, or can induce the activation of secondary detrimental pathways that lead to peri-hemorrhagic edema, inflammation, and apoptosis (1,2). Thus, primary clot reduction theoretically represents a promising treatment target.…”

“…Patients with VKA-related ICH are at risk of a higher secondary hematoma expansion rate, a larger hematoma volume, and hence a poor functional outcome (16,17). Although the available findings on the MIS technique are encouraging, no sufficient data on efficacy and safety of existing MIS technologies (18) are available for patients in VKA-related hemorrhage (2). The aim of the present retrospective case-control study was therefore to generate novel data on the safety and efficacy of a minimally invasive catheter evacuation technique in patients with VKA-related deep and lobar ICH.…”

Differences in neurosurgical treatment of intracerebral haemorrhage: a nation-wide observational study of 578 consecutive patients

“…Treatment for ICH encompasses both medical and surgical strategies [ 8 , 50 , 51 ]. The rationale for surgical intervention is reduction of mass effect and elevated intracranial pressure (ICP), as well as a possible improvement in perihaemorrhagic brain tissue environment by enhancing cerebral perfusion and by removing neurotoxic substances [ 24 , 29 , 34 , 45 , 48 ].…”