What are the indications for neurosurgical (surgical intervention by a neurosurgeon) intervention in intracerebral hemorrhage (ICH)?

Indications for Neurosurgical Intervention in Intracerebral Hemorrhage (ICH)

Urgent neurosurgical consultation is essential for patients with cerebellar hemorrhage, especially those with altered consciousness or new brainstem symptoms, and for patients with acute hydrocephalus requiring external ventricular drainage. 1

Primary Indications for Neurosurgical Intervention

Cerebellar Hemorrhage

• Patients with cerebellar hemorrhage should be referred for urgent neurosurgical consultation, particularly with altered level of consciousness or new brainstem symptoms 1
• Cerebellar hematomas 3 mL or larger typically require surgical evacuation due to the risk of brainstem compression and obstructive hydrocephalus 2

Hydrocephalus

• Patients with new onset of acute hydrocephalus requiring placement of external ventricular drain (EVD) should be referred for urgent neurosurgical consultation 1
• External ventricular drainage is indicated in patients with ICH with intraventricular extension and hydrocephalus 1

Supratentorial ICH

• Surgical intervention has not been shown to be superior to conservative management for most patients with supratentorial ICH 1
• However, in select patients with higher level of consciousness (especially GCS score 9-12), early surgical intervention may be considered 1
• Patients with lobar hemorrhages within 1 cm of the cortical surface might benefit from surgery 1
• Patients with temporal lobe hematoma and impending brain stem compression require surgical intervention 2

Mass Effect and Increased Intracranial Pressure

• Early consultation with a neurosurgeon is recommended in cases where decompressive craniectomy is considered 1
• Decompressive craniectomy may be indicated in patients with space-occupying lesions with acute intracranial hypertension 1

Patient Selection Factors

Clinical Factors

• GCS score 9-12: These patients may benefit from surgical intervention 1
• Patients with moderate to severe ICH (volume ≥30 mL) or GCS score <8 may benefit from neurosurgical evaluation 1
• Patients in deep coma (GCS score 5-8) tend to do better with medical management 1

Hemorrhage Characteristics

• Location: Lobar hemorrhages within 1 cm of cortical surface may benefit from surgery 1
• Volume: Moderate to severe ICH (≥30 mL) warrants neurosurgical evaluation 1
• Intraventricular extension: Presence of IVH increases the need for neurosurgical care 1

Surgical Approaches

Conventional Craniotomy

• The International Surgical Trial in Intracerebral Haemorrhage (STICH) found no overall statistically significant difference in mortality or functional outcome between surgical and medical treatment groups 1
• Subgroup analyses suggested potential benefit for patients with lobar hemorrhages within 1 cm of the cortical surface 1

Minimally Invasive Surgery (MIS)

• MIS for supratentorial ICH has increased significantly and appears to be associated with decreased mortality and improved functional outcomes compared to medical management 3
• Current MIS techniques include stereotactic aspiration and thrombolysis, endoport-mediated evacuation, and endoscopic aspiration 3
• MIS can facilitate significant hematoma volume reduction with potentially less morbidity than conventional open surgical approaches 3, 4

Special Considerations

Anticoagulation-Related ICH

• Patients with ICH related to anticoagulation require prompt assessment and reversal of coagulopathy 1
• Warfarin-related coagulopathy should be reversed with prothrombin complex concentrate (PCC) and vitamin K 1, 4
• Direct oral anticoagulants (DOACs) require specific reversal strategies and urgent hematology consultation 1

Post-Surgical Management

• Patients should be admitted to a stroke unit or neuro-intensive care unit for monitoring and care 1
• Systemic anticoagulation monitoring and resumption are necessary post-operatively if indicated 1
• Early and aggressive treatment, including meticulous control of blood pressure and other systemic physiological variables, improves outcomes 5

Pitfalls and Caveats

• Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 hours 4
• Surgical intervention decisions should be made on a case-by-case basis with multidisciplinary input 1
• The timing of surgery and its relationship to ongoing hematoma expansion (benefit vs. harm) are important considerations 1
• For most patients, decisions related to DNR orders or palliative care should be deferred for 24 to 48 hours after stroke onset 1