What is the incidence of rebleeding after surgical evacuation of spontaneous intracerebral hemorrhage?

Rate of Rebleeding After Surgical Intervention for Intracerebral Hemorrhage

The rate of postoperative rebleeding after surgical evacuation of spontaneous ICH varies significantly by surgical technique and timing: 10% after conventional craniotomy, 5-6% after minimally invasive CT- or ultrasound-guided aspiration, 0-10% (mean 4%) after stereotactic aspiration with thrombolytic therapy, and notably 36% (4 of 11 patients) after ultra-early craniotomy within 4 hours of symptom onset. 1

Rebleeding Rates by Surgical Technique

Conventional Craniotomy

• Postoperative rebleeding occurs in approximately 10% of patients undergoing standard craniotomy for ICH evacuation 1
• The timing of surgery significantly impacts rebleeding risk, with ultra-early intervention carrying the highest risk 1

Minimally Invasive Approaches

• CT-guided or ultrasound-guided aspiration demonstrates lower rebleeding rates of 5-6% compared to conventional craniotomy 1
• These techniques removed 71% of hematoma volume with CT guidance and 81% with ultrasound guidance, with rebleeding rates independent of surgical timing 1

Stereotactic Aspiration with Thrombolytic Therapy

• Rebleeding rates range from 0-10% with a mean of 4% across 392 cases using stereotactic aspiration combined with thrombolytic agents 1
• One multicenter randomized trial reported a 35% rebleeding rate in the urokinase group versus 17% in conservatively managed patients, though this included intraventricular thrombolysis 1

Endoscopic Evacuation

• Recent data from 127 patients undergoing endoscopic evacuation of hematoma showed postoperative recurrent hemorrhage in 7.1% overall 2
• Among patients with the spot sign on CT angiography, the rebleeding rate increased to 21.7% (5 of 23 patients) 2
• Only 3.8% of patients without the spot sign experienced rebleeding (4 of 104 patients), making the spot sign a strong independent predictor (OR 5.81,95% CI 1.26-26.88) 2

Critical Timing Considerations

Ultra-Early Surgery (Within 4 Hours)

• The highest rebleeding risk occurs with ultra-early craniotomy, with 36% of patients (4 of 11) experiencing acute rebleeding 1
• Among those who rebled, 75% died, leading to the hypothesis that craniotomy itself may facilitate early rebleeding that would otherwise occur spontaneously 1
• This catastrophic rebleeding rate contributed to higher 6-month mortality in the surgical group (36%) versus medical management (29%) 1

Surgery Within 12 Hours

• Early postoperative clot recurrence was markedly reduced when surgery was performed between 4-12 hours compared to ultra-early intervention 1
• Mortality decreased to 18% in this timeframe, though functional outcomes remained similar 1

Key Clinical Pitfalls

The Ultra-Early Surgery Paradox

The evidence reveals a critical warning: attempting to prevent hematoma expansion through ultra-early craniotomy may paradoxically increase rebleeding risk and mortality 1. The surgical disruption of tissue planes and inability to achieve complete hemostasis in actively bleeding vessels likely explains this phenomenon.

Spot Sign as a Predictor

• Preoperative CT angiography identifying the spot sign should trigger heightened vigilance for postoperative rebleeding 2
• Complete and meticulous control of bleeding in the operative field is essential when the spot sign is present 2
• Consider delaying surgery or using minimally invasive techniques in spot sign-positive patients 2

Technique Selection Impact

The choice of surgical technique directly impacts rebleeding risk, with minimally invasive approaches demonstrating superior safety profiles compared to conventional craniotomy 1. This advantage persists across different surgical timings and may relate to reduced tissue trauma and better preservation of surrounding vascular structures.