From the Guidelines
Surgical procedures for intracerebral hemorrhage (ICH) patients, such as craniotomy, minimally invasive surgery (MIS), external ventricular drainage (EVD), and decompressive craniectomy, are performed to reduce intracranial pressure, prevent secondary brain injury, and improve neurological outcomes, with the most recent guidelines suggesting that MIS may be useful to reduce mortality and improve functional outcomes 1. The decision to perform surgery depends on various factors, including hemorrhage size, location, patient age, neurological status, and comorbidities. Some key points to consider include:
- Hemorrhage size: typically >30mL
- Location: cerebellar, supratentorial, or infratentorial
- Patient age and neurological status: younger patients with milder deficits may benefit from surgery
- Comorbidities: presence of hydrocephalus, brainstem compression, or other conditions that may affect surgical outcomes The most recent guidelines from the American Heart Association/American Stroke Association recommend that patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 1. Additionally, MIS with endoscopic or stereotactic aspiration, with or without thrombolytic use, is safe and may be useful to reduce mortality, although the level of evidence for this is lower 1. Decompressive craniectomy may also be considered in patients with large hematomas and significant midline shift or elevated intracranial pressure refractory to medical management 1. It is essential to carefully evaluate the risk-benefit ratio for each individual patient and consider the latest evidence-based guidelines when making surgical decisions for ICH patients. In general, surgery is considered within 24-72 hours of bleeding onset, and the choice of surgical procedure depends on the specific characteristics of the patient and the hemorrhage. Overall, the goal of surgical intervention is to improve outcomes and reduce morbidity and mortality in ICH patients, and the most recent evidence suggests that MIS and other surgical procedures may be effective in achieving this goal 1.
From the Research
Common Surgical Procedures for ICH Patients
- Surgical hematoma evacuation can reduce mass effect and decrease cytotoxic effects from blood product breakdown 2
- Minimally invasive surgery (MIS) is emerging as a treatment modality for spontaneous ICH, with techniques including stereotactic aspiration and thrombolysis, endoport-mediated evacuation, and endoscopic aspiration 2
- Decompressive craniectomy (DC) is another surgical option, which may overcome the need for subsequent surgery in accommodating postoperative mass effect in residual bleeds and rebleeds 3
- Craniotomy is also a common surgical procedure for ICH patients, with some studies suggesting better functional outcomes compared to DC 4
Reasons for Surgical Procedures
- To reduce mortality and improve functional outcomes in ICH patients 2, 3, 4
- To evacuate hematoma and reduce intracranial pressure 2, 3, 4, 5
- To prevent further brain damage and improve patient prognosis 2, 3, 4, 5
- To manage post-traumatic intracranial hematomas, such as acute subdural hematoma, acute epidural hematoma, cerebral contusion, and intracerebral hematoma 6
Comparison of Surgical Procedures
- DC with hematoma evacuation does not appear to provide a significant advantage over standard craniotomy with regard to functional outcomes and mortality 3
- Craniotomy may be associated with better functional outcomes compared to DC in selected large ICH patients 4
- Minimally invasive surgery may be associated with decreased mortality and improved functional outcome compared to medical management 2