From the Guidelines
Evacuation of hypertensive intracranial bleeding is indicated for patients with cerebellar hemorrhage larger than 15 mL, neurological deterioration, brainstem compression, or hydrocephalus, as well as for supratentorial ICHs with significant mass effect or deterioration, as evidenced by the 2022 American Heart Association/American Stroke Association guideline 1. The decision to evacuate a hypertensive intracranial hemorrhage should be based on the patient's individual clinical scenario, taking into account the size and location of the hemorrhage, as well as the patient's neurological status.
- Key considerations for evacuation include:
- Cerebellar hemorrhages larger than 15 mL
- Neurological deterioration
- Brainstem compression
- Hydrocephalus
- Supratentorial ICHs with significant mass effect or deterioration Minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages have demonstrated reductions in mortality, although the clinical trial evidence for improvement of functional outcome with these procedures is neutral 1.
- The management of hypertensive intracranial bleeding also involves concurrent control of blood pressure, reversal of anticoagulation if applicable, and management of increased intracranial pressure through measures such as head elevation, osmotic therapy, and ventilation control. The goal of evacuation is to reduce intracranial pressure, minimize secondary brain injury from blood products, and prevent herniation, ultimately improving outcomes and quality of life for patients with hypertensive intracranial bleeding 1.
From the Research
Indications for Evacuation of Hypertensive Intracranial Bleeding
- The decision to evacuate a hypertensive intracranial bleeding depends on various factors, including the size and location of the hematoma, the patient's neurological status, and the presence of signs indicating increased intracranial pressure 2, 3, 4.
- Patients with large cerebellar or temporal intracerebral hemorrhage may benefit from emergent hematoma evacuation 2.
- Surgical treatment of patients with primary supratentorial intracerebral hemorrhage and altered state of consciousness can have a positive role in selected cases, by minimizing the life-threatening progression of intracranial hypertension 3.
- The role of surgery in the management of hypertensive intracerebral hemorrhage is still controversial, and the ideal surgical management is still to be determined 4, 5.
- Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products 5.
Patient Selection for Evacuation
- Patients with severe intraventricular hemorrhage, hydrocephalus, or elevated intracranial pressure may benefit from ventriculostomy 2.
- Comatose patients and patients at risk of cerebral herniation may require surgical evacuation of the hematoma, as it may be lifesaving 5.
- Patients with large intracerebral hemorrhage (volume > 30 cubic centimeters) or symptomatic perihaematoma edema may benefit from surgical evacuation, as well as management of serum sodium levels to minimize edema expansion and mass effect 2.
Surgical Techniques
- Several surgical techniques have been considered for the evacuation of hypertensive intracranial bleeding, including open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis 5.
- Open craniotomy is the most studied approach in this clinical scenario, but its benefits are still debated 5.
- Decompressive craniectomy and dural enlargement may be useful in severely compromised patients, as it can help reduce intracranial pressure and improve outcomes 3.