Hemorrhagic stroke surgery
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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.[1][2]
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.[2][3][4][5]
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.[6][7]
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.[6][8]
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.[2][9]
Standard craniotomy should be considered in following conditions:
- 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 in following conditions:
- 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.[10]
- Controlling ICP via means other than hematoma evacuation, such as VC insertion alone, is considered insufficient, is not recommended, and may actually be harmful.[11]
Intraventricular hemorrhage
- using of ventricular catheter (VC) alone may be ineffective because of difficulty maintaining catheter patency and the slow removal of intraventricular blood.[12]
- There are now reports of alternative procedures for IVH, such as endoscopic surgical evacuation and ventriculostomy.
2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage[13]
Hemostasis and Coagulopathy, Antiplatelet Agents, and DVT Prophylaxis: Recommendations
Surgical Treatment of ICH: Recommendations
| Class I |
| "1.Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible (Level of Evidence: B)" |
| Class III (Harm) |
| "1. Initial treatment of patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction is not recommended (Level of Evidence: C)" |
| Class IIb |
| "1. For most patients with supratentorial ICH, the usefulness of surgery is not well established (Level of Evidence: A)" |
| "2. A policy of early hematoma evacuation is not clearly beneficial compared with hematoma evacution when patients deteriorate (Level of Evidence: A)" |
| "3. Supratentorial hematoma evacuation in deteriorating patients might be considered as a life-saving measure (Level of Evidence: C)" |
| "4.Decompressive hemicraniectomy (DC) with or without hematoma evacuation might reduce mortality for patients with supratentorial ICH who are in a coma, have large hematomas with significant midline shift, or have elevated ICP refractory to medical management (Level of Evidence: C)" |
| "5. The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain (Level of Evidence: B)" |
References
- ↑ Zhou X, Chen J, Li Q, Ren G, Yao G, Liu M, Dong Q, Guo J, Li L, Guo J, Xie P. Minimally invasive surgery for spontaneous supratentorial intra- cerebral hemorrhage: a meta-analysis of randomized controlled trials. Stroke. 2012;43:2923–2930. doi: 10.1161/STROKEAHA.112.667535.
- ↑ 2.0 2.1 2.2 Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM; STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial [published cor- rection appears in Lancet. 2013;382:396]. Lancet. 2013;382:397–408. doi: 10.1016/S0140-6736(13)60986-1.
- ↑ Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Early surgery versus initial conservative treatment in patients with spontane- ous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005;365:387–397. doi: 10.1016/S0140-6736(05)17826-X.
- ↑ Pantazis G, Tsitsopoulos P, Mihas C, Katsiva V, Stavrianos V, Zymaris S. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: a prospective randomized study. Surg Neurol. 2006;66:492–501.
- ↑ Delcourt C, Huang Y, Arima H, Chalmers J, Davis SM, Heeley EL, Wang J, Parsons MW, Liu G, Anderson CS; INTERACT1 Investigators. Hematoma growth and outcomes in intracerebral hemorrhage: the INTERACT1 study. Neurology. 2012;79:314–319. doi: 10.1212/ WNL.0b013e318260cbba.
- ↑ 6.0 6.1 Wang WZ, Jiang B, Liu HM, Li D, Lu CZ, Zhao YD, Sander JW. Minimally invasive craniopuncture therapy vs. conservative treat- ment for spontaneous intracerebral hemorrhage: results from a ran- domized clinical trial in China. Int J Stroke. 2009;4:11–16. doi: 10.1111/j.1747-4949.2009.00239.x.
- ↑ Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF; MISTIE Investigators. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intrace- rebral hemorrhage evacuation decreases perihematomal edema. Stroke. 2013;44:627–634. doi: 10.1161/STROKEAHA.111.000411.
- ↑ Fung C, Murek M, Z’Graggen WJ, Krähenbühl AK, Gautschi OP, Schucht P, Gralla J, Schaller K, Arnold M, Fischer U, Mattle HP, Raabe A, Beck J. Decompressive hemicraniectomy in patients with supratento- rial intracerebral hemorrhage. Stroke. 2012;43:3207–3211. doi: 10.1161/ STROKEAHA.112.666537.
- ↑ Mendelow AD, Gregson BA, Mitchell PM, Murray GD, Rowan EN, Gholkar AR; STICH II Investigators. Surgical Trial in Lobar Intracerebral Haemorrhage (STICH II) protocol. Trials. 2011;12:124. doi: 10.1186/1745-6215-12-124.
- ↑ Da Pian R, Bazzan A, Pasqualin A. Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurol Res. 1984;6:145–151.
- ↑ van Loon J, Van Calenbergh F, Goffin J, Plets C. Controversies in the management of spontaneous cerebellar haemorrhage: a consecutive series of 49 cases and review of the literature. Acta Neurochir (Wien). 1993;122:187–193.
- ↑ 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.
- ↑ 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhagehttp://stroke.ahajournals.org/content/early/2015/05/28/STR.0000000000000069 Accessed on November 10, 2016