Hemorrhagic stroke surgery: Difference between revisions
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*Surgical decompression in patients whom cerebellar hemorrhage is associated with [[brainstem]] compression or [[hydrocephalus]] or patients with cerebellar hemorrhages >3 cm in diameteris are associated with good outcomes. | *Surgical decompression in patients whom cerebellar hemorrhage is associated with [[brainstem]] compression or [[hydrocephalus]] or patients with cerebellar hemorrhages >3 cm in diameteris are associated with good outcomes. | ||
*Controlling ICP via means other than hematoma evacuation, such as VC insertion alone, is considered insufficient, is not recommended, and may actually be harmfu.239 | *Controlling ICP via means other than hematoma evacuation, such as VC insertion alone, is considered insufficient, is not recommended, and may actually be harmfu.239 | ||
===Intraventricular hemorrhage=== | ====Intraventricular hemorrhage==== | ||
*using of ventricular catheter (VC) alone may be ineffective because of difficulty maintaining catheter patency and the slow removal of intraventricular blood.<ref>Huttner HB, Köhrmann M, Berger C, Georgiadis D, Schwab S. Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study. J Neurosurg. 2006;105:412–417. doi: 10.3171/jns.2006.105.3.412.</ref> | *using of ventricular catheter (VC) alone may be ineffective because of difficulty maintaining catheter patency and the slow removal of intraventricular blood.<ref>Huttner HB, Köhrmann M, Berger C, Georgiadis D, Schwab S. Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study. J Neurosurg. 2006;105:412–417. doi: 10.3171/jns.2006.105.3.412.</ref> | ||
*There are now reports of alternative procedures for IVH, such as endoscopic surgical evacuation and [[ventriculostomy]]. | *There are now reports of alternative procedures for IVH, such as endoscopic surgical evacuation and [[ventriculostomy]]. | ||
Revision as of 14:31, 17 November 2016
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Hemorrhagic stroke Microchapters |
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Diagnosis |
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Treatment |
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AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (2015) |
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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012) |
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AHA/ASA Guideline Recommendation for the Primary Prevention of Stroke (2014) |
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AHA/ASA Guideline Recommendations for Prevention of Stroke in Women (2014) Sex-Specific Risk Factors
Risk Factors Commoner in Women |
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Case Studies |
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Hemorrhagic stroke surgery On the Web |
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American Roentgen Ray Society Images of Hemorrhagic stroke surgery |
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Risk calculators and risk factors for Hemorrhagic stroke surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The role of surgery for most patients with spontaneous ICH remains controversial. The theoretical rationale for hematoma evacuation revolves around the concepts of preventing herniation, reducing ICP, and decreasing the pathophysiological impact of the hematoma on surrounding tissue by decreasing mass effect or the cellular toxicity of blood products. Additionally, the current recommendations do not apply to intracranial hemorrhage caused by trauma or underlying structural lesions such as aneurysms and arteriovenous malformations, because these patients were not included in the described ICH surgery trials.
The indications for surgery in patients with ICH vary with the site of the bleed
Surgery
- The indications for surgery in patients with ICH vary with the site of the bleed
Timing of surgery
- Timing of surgery for ICH remains controversial. Randomized prospective trials to date have reported on a wide time frame for surgery that ranges from 4 to 96 hours after symptom onset. Ultra-early craniotomy (within 4 hours from ictus) was associated with an increased risk of rebleeding in a study that involved 24 patients.
Surgical techniques
Open craniotomy
Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH [1]. Other methods include endoscopic hemorrhage aspiration, use of fibrinolytic therapy to dissolve the clot followed by aspiration, and CT-guided stereotactic aspiration. Studies of these less invasive techniques are in progress
Minimally invasive surgical evacuation of ICH
Several recent randomized studies have shown minimally invasive aspiration associated with better outcomes with less invasive approaches compared to standard craniotomies.
Site of the bleed
Supratentorial hemorrhage
Early hematoma evacuation has not been shown to be beneficial in the 2 latest randomized trials, and it is still unclarified whether surgery may benefit specific groups of patients with supratentorial ICH. Therefore, the routine evacuation of supratentorial ICH in the first 96 hours is not recommended. Standard craniotomy should be considered:
- Hematoma near the cortical surface (lobar clots >30 mL within 1 cm of the surface)
- Recent onset of hemorrhage
- Ongoing clinical deterioration
- Involvement of the nondominant hemisphere
Craniotomy should not be considered:
- Patients who are either fully alert or deeply comatose.
Posterior fossa hemorrhage
Because of the narrow confines of the posterior fossa, obstructive hydrocephalus and local mass effect on the brainstem can result in rapid deterioration of the patient with cerebellar hemorrhage.
- Surgical decompression in patients whom cerebellar hemorrhage is associated with brainstem compression or hydrocephalus or patients with cerebellar hemorrhages >3 cm in diameteris are associated with good outcomes.
- Controlling ICP via means other than hematoma evacuation, such as VC insertion alone, is considered insufficient, is not recommended, and may actually be harmfu.239
Intraventricular hemorrhage
- using of ventricular catheter (VC) alone may be ineffective because of difficulty maintaining catheter patency and the slow removal of intraventricular blood.[1]
- There are now reports of alternative procedures for IVH, such as endoscopic surgical evacuation and ventriculostomy.
References
- ↑ Huttner HB, Köhrmann M, Berger C, Georgiadis D, Schwab S. Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case-control study. J Neurosurg. 2006;105:412–417. doi: 10.3171/jns.2006.105.3.412.