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Continuous Medical Education

Department of Neurosurgery, HKL 14 February 2007

EPIDEMIOLOGY
For a patient who presents with the abrupt onset of a new focal neurological deficit :  5% are seizure, tumour or psychogenic  95% are vascular
– 15% haemorrhagic  ICH, SAH, SDH – 85% ischaemic infarct  Unknown, lacunar, cardiogenic embolus, large artery cerebrovascular lesion, tandem arterial pathology, atherosclerotic plaques in the aortic arch

EPIDEMIOLOGY



Incidence 12-15/100,000/yr Intracerebral hemorrhage (ICH) is more than twice as common as subarachnoid hemorrhage (SAH) Much more likely to result in death or major disability than cerebral infarction or SAH 35% to 50% can be expected to die within the first month after bleeding Only 10% of patients are living independently 1 month after the hemorrhage 20% are independent at 6 months

EPIDEMIOLOGY  Risk factors – Advancing age and hypertension are the most important risk factors – Age : >after 55. doubles with each decade – Gender : more common in men – Ethnic : More common among young and middle-age blacks than whites of similar ages More common in Asians compared to whites – Previous CVA increases risk by 23:1 – Alcohol consumption – Drug abuse – Liver dysfunction .

) Haemorrhage into brain tumours Septic embolism Haemorrhagic infarct Inflammatory diseases of blood vessels Amyloidosis . 3. 2. 5. 4. 7. aplastic anaemia.EPIDEMIOLOGY Causes of Intracranial Haemorrhage 1. Primary ( hypertensive ) intracerebral haemorrhage Ruptured saccular aneurysm Ruptured AVM Haemorrhagic disorders ( leukaemia. 8. haemophilia. 9. anticoagulant therapy. 6..

globus pallidus 50% – Thalamus 15% – Pons 10-15% – Cerebellum 10% – Cerebral white matter 10% – Brain stem 6% – Lenticulostriates – putaminal – Thalamoperforators – Paramedian branches of the basilar artery .EPIDEMIOLOGY  Locations of haemorrhage  Common arterial feeders of ICH – Putamen. internal capsule. lenticular nucleus.

EPIDEMIOLOGY  Lobar haemorrhage vs deep haemorrhage – Haemorrhage into the occipital. infratentorial structures – More likely associated with structural abnormalities – More common in patients with high alcohol consumption – More benign outcome – Causes       Extension of deep haemorrhage Cerebral amyloid angiopathy Trauma Haemorrhagic transformation Tumour AVM/aneurysm . thalamus. temporal. frontal and parietal lobes as opposed to deep structures – BG.

PATHOPHYSIOLOGY     Chronic hypertension stimulates the brain's blood vessels to make gradual. this results in hyalinization and lipidosis of the blood vessels This process segmentally affects the smaller penetrating arteries (<200 mm in diameter) . with an accumulation of lipid-laden macrophages and cholesterol deposits. adaptive changes in an attempt to preserve the bloodbrain barrier One gradual change that may develop is lipohyalinosis Subintimal fibroblast proliferation occurs.

as well as focal aneurysmal dilatation (Charcot-Bouchard intracerebral microaneurysm) Hemorrhage may then arise from rupture of the Charcot-Bouchard aneurysms .PATHOPHYSIOLOGY    Plasma leakage from persistently elevated blood pressures also can result in hyaline degeneration of the cerebral blood vessels Arterial sclerosis and fibrinoid necrosis may occur.

CT of the head is the imaging procedure of choice in the initial evaluation of suspected ICH Angiography should be considered for all patients without a clear cause of hemorrhage who are surgical candidates. or brain stem and in whom CT findings do not suggest a structural lesion . 3. thalamus. 2. Angiography is not required for older hypertensive patients who have a hemorrhage in the basal ganglia. cerebellum. normotensive patients who are clinically stable.Management Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (1999 American Heart Association ) 1. particularly young.

They should also be considered to look for cavernous malformations in normotensive patients with lobar hemorrhages and normal angiographic results who are surgical candidates . MRI and MRA are helpful and may obviate the need for contrast cerebral angiography in selected patients.Management Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (1999 American Heart Association ) 4.

Treatment     Medical Surgical There is a lack of proven medical or surgical treatment for ICH This has lead to great variation among physicians concerning both surgical and medical treatment Well-designed and well-executed randomized treatment studies of ICH are urgently needed  .Management .

Treatment Medical        Airway and oxygenation Blood pressure ICP Fluid management Prevention of seizures Body temperature Other issues .Management .

airway protection and adequate ventilation are critical Patients who exhibit a decreasing level of consciousness or signs of brain stem dysfunction are candidates Intubation should be guided by imminent respiratory insufficiency rather than an arbitrary cutoff such as a specific Glasgow Coma Scale (GCS) score .Treatment Airway and oxygenation    “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 Although intubation is not required for all patients.Management .

Treatment  Indications for intubation – hypoxia (pO2 <60 mm Hg or PCO2 >50 mm Hg) – risk of aspiration with or without impairment of arterial oxygenation   All patients with endotracheal tubes receive nasogastric or orogastric tubes to prevent aspiration and are monitored for cuff pressure every 6 hours Endotracheal tubes with soft cuffs can generally be maintained for 2 weeks “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 .Management .

elective tracheostomy should be performed after 2 weeks Oxygen should be administered to all patients presenting with a possible ICH “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 .Treatment   In the presence of prolonged coma or pulmonary complications.Management .

Treatment Blood Pressure  Optimal level of a patient's blood pressure should be based on individual factors – Chronic hypertension – Raised ICP – Cause of haemorrhage   The theoretical rationale for lowering blood pressure is to decrease the risk of on going bleeding from ruptured small arteries and arterioles Conversely. over aggressive treatment of blood pressure may decrease cerebral perfusion pressure and theoretically worsen brain injury “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 .Management .

Management .Treatment  Blood pressure levels be maintained below a mean arterial pressure of 130 mm Hg in persons with a history of hypertension (level of evidence V. cerebral perfusion pressure (MAP–ICP) should be kept >70 mm Hg (level of evidence V. grade C recommendation)    In patients with elevated ICP who have an ICP monitor. grade C recommendation) Mean arterial blood pressure >110 mm Hg should be avoided in the immediate postoperative period If systolic arterial blood pressure falls below 90 mm Hg. pressors should be given “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 .

2 mg Q 6 h as needed 1. institute nitroprusside. If ICP monitoring is available. avoid labetalol in patients with asthma). Phenylephrine Dopamine Norepinephrine 2–10 µg · kg-1 · min-1 2–20 µg · kg-1 · min-1 Titrate from 0. lisinopril. 2. If systolic BP is 180 to 230 mm Hg. or mean arterial BP 130 mm Hg on 2 readings 20 minutes apart. or verapamil.2 µg · kg-1 · min-1 . defer antihypertensive therapy. particularly for low systolic blood pressure such as <90 mm Hg. 4. Low blood pressure Volume replenishment is the first line of approach. enalapril. If systolic BP is <180 mm Hg and diastolic BP <105 mm Hg.5–10 µg · kg-1 · min-1 Hydralazine Enalapril 10–20 mg Q 4–6 h 0. maintenance use. If hypotension persists after correction of volume deficit.625–1. 3. esmolol. or other smaller doses of easily titratable intravenous medications such as diltiazem. continuous infusions of pressors should be considered. cerebral perfusion pressure should be kept at >70 mm Hg. diastolic BP 105 to 140 mm Hg. institute intravenous labetalol. 50–200 µg · kg-1 · min-1 0. Isotonic saline or colloids can be used and monitored with central venous pressure or pulmonary artery wedge pressure. Choice of medication depends on other medical contraindications (eg. If systolic BP is >230 mm Hg or diastolic BP >140 mm Hg on 2 readings 5 minutes apart.Elevated blood pressure Labetalol Esmolol Nitroprusside 5–100 mg/h by intermittent bolus doses of 10–40 mg or continuous drip (2–8 mg/min) 500 µg/kg as a load.05–0.

controlled hyperventilation.Treatment ICP     ICP may be managed through head position.Management . and barbiturate coma Elevated ICP is defined as intracranial pressure 20 mm Hg for >5 minutes A therapeutic goal for all treatment of elevated ICP is ICP <20 mm Hg and cerebral perfusion pressure (CPP) >70 mm Hg Patients with suspected elevated ICP and deteriorating level of consciousness are candidates for invasive ICP monitoring “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 . osmotherapy.

Treatment  In general. grade C recommendation)   Ventricular drains should be used in patients with or at risk for hydrocephalus Because of infectious complications. grade C recommendation) “Guidelines for the Management of Spontaneous Intracerebral Hemorrhage” by the American Heart Association 1999 . external drainage devices must be checked regularly.Management . ICP monitors should be placed in (but not limited to) patients with a GCS score of <9 and all patients whose condition is thought to be deteriorating due to elevated ICP (level of evidence V. and duration of placement ideally should not exceed 7 days (level of evidence V.

if hyperventilation is instituted for elevated ICP. gradual normalization of serum PCO2 should occur over a 24.Treatment     Use of anti-infectious prophylaxis is recommended (level of evidence V.to 48-hour period In general. PCO2 should be maintained between 30 and 35 mm Hg until ICP is controlled .Management . grade C recommendation) The beneficial effect of sustained hyperventilation on ICP is unresolved When hyperventilation is deemed no longer necessary.

Emergency ICP therapy
– Comatose patient with clinical signs of brainstem herniation
Head up 30 degree  Mannitol 20% 1-1.5gm/kg  Hyperventilation Pco2 30-35 mmHg

– ―Buy time‖ before a definitive neurosurgical procedure

Management of ICP

Osmotherapy

– The first medical line of defense is osmotherapy. However, it should not be used prophylactically. – Mannitol 20% (0.25–0.5 g/kg every 4 h) is reserved for patients with type B ICP waves, progressively increasing ICP values, or clinical deterioration associated with mass effect (level of evidence V, grade C recommendation). – Due to its rebound phenomenon, mannitol is recommended for only 5 d. – To maintain an osmotic gradient, furosemide (10 mg Q 2– 8 h) may be administered simultaneously with osmotherapy. – Serum osmolality should be measured twice daily in patients receiving osmotherapy and targeted to 310 mOsm/L.

Management of ICP

No steroids
– Corticosteroids in ICH are generally avoided because multiple potential side effects must be considered and clinical studies have not shown benefit (level of evidence II, grade B recommendation).

lowers ICP 25% to 30% in most patients (levels of evidence III through V. – Reduction of cerebral blood flow is almost immediate. although peak ICP reduction may take up to 30 minutes after pCO2 is changed.Management of ICP  Hyperventilation – Hypocarbia causes cerebral vasoconstriction. . grade C recommendation). best achieved by raising ventilation rate at constant tidal volume (12–14 mL/kg). – Reduction of pCO2 to 35–30 mm Hg. – Failure of elevated ICP to respond to hyperventilation indicates a poor prognosis.

such as vecuronium or pancuronium. grade C recommendation). with only minor histamine liberation and ganglion-blocking effects. Alternatively. straining. – Patients with critically elevated ICP should be pretreated with a bolus of a muscle relaxant before airway suctioning. – Nondepolarizing agents. grade C recommendation). lidocaine may be used for this purpose.Management of ICP  Muscle relaxants – Neuromuscular paralysis in combination with adequate sedation can reduce elevated ICP by preventing increases in intrathoracic and venous pressure associated with coughing. suctioning. are preferred in this situation (levels of evidence III through V. or "bucking" the ventilator (levels of evidence III through V. .

Management of ICP  Barbiturate Coma – Short acting thiopental 2-5 mg/kg slow stat then 15mg/kg/hour – Decreased cerebral metabolism. decreased CBF and CBV – Beware of hypotension – Max reduction in cerebral metabolism is accompanied by electrocerebral silence .

Treatment Fluid Management  The goal of fluid management is euvolemia  CVP should be maintained between 5 and 12 mm Hg or pulmonary wedge pressure at 10 to 14 mm Hg  Fluid balance is calculated by measuring daily urine production and adding for insensible water loss (urine output plus 500 mL for insensible loss plus 300 mL per degree in febrile patients)  Electrolytes (sodium. and magnesium) should be checked and substituted according to normal values . potassium. calcium.Management .

Treatment Prevention of Seizures   Seizure activity can result in neuronal injury and destabilization of an already critically ill patient and must be treated aggressively In patients with ICH. grade C recommendation) . although data supporting this therapy are lacking (level of evidence V.Management . prophylactic antiepileptic therapy (preferably phenytoin with doses titrated according to drug levels [14 to 23 µg/mL]) may be considered for 1 month and then tapered and discontinued if no seizure activity occurs during treatment.

and urine) should be obtained and Enteral feeding should be started within 48h to reduce risk of malnutrition .5° C Febrile patients or those at risk for infection. appropriate cultures and smears (tracheal. blood.Treatment Body Temperature    antibiotics given Nutrition  Body temperature should be maintained at normal levels Acetaminophen 650 mg or cooling blankets should be used to treat hyperthermia >38.Management .

. Henze T. Early heparin therapy in patients with spontaneous intracerebral haemorrhage. Voth E.Management .Treatment DVT prevention – Dynamic compression stockings should be placed on admission – Medications at day 2 SC heparin 5000u bd  LMW heparin enoxaparin 40 mg daily  No increased in intracranial bleeding  Boeer A. Prange HW.

Reversal of coagulation – Warfarin – increase risk of ICH 5-10X  Reverse with FFP & Vit K – Aim INR <1.4 – Low molecule heparin  Reverse with protamine sulfate 1mg to 1 mg enoxaparin .

particularly for bedridden patients with hemiplegia.Treatment Other Issues  Many patients who are delirious or stuporous are agitated  Prudent use of minor and major tranquilizers is recommended  Short-acting benzodiazepines or propofol are preferred  Pulmonary embolism is a common threat during the recovery period.Management . speech therapy. physical therapy. and occupational therapy should be initiated as soon as possible . Pneumatic devices decrease the risk of pulmonary embolism during hospitalization  Depending on the patient's clinical state.

Management . an advantage of neurosurgical intervention over medical treatment has not been established .Treatment Surgical Treatment Management of cerebral haemorrhage Karolinska Stroke Update Consensus Statement 2004  As yet.

Surgical Treatment ICH Treatment Targets • Expanding hematoma – Local shear forces – Mass effect – ↑ Intracranial pressure (ICP) • Local toxic effects – Direct toxicity of blood products – Edema – Excitotoxicity .

Ultra-early haemostatic therapy by using the recombinant activated factor VIIa (The Novo-7 trial) . – c. – a.Treatment  Recently.Management . Stereotactic aspiration combined with instillation of fibrynolitic agent (The SICHPA trial). three RCTs evaluating new strategies for the treatment of the ICH have been completed. – b. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial ICH (The International STICH trial).

INTERPRETATION: Patients with spontaneous supratentorial intracerebral hemorrhage in neurosurgical units show no overall benefit from early surgery when compared with initial conservative treatment. Teasdale GM.66 –1.2 to 7. Lancet 2005. 51 patients were lost to follow-up. 95% confidence interval 0. 122 (26%) had a favorable outcome compared with 118 (24%) of 496 randomized to initial conservative treatment (odds ratio 0. relative benefit 10% (–13 to 33).Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomized trial    Comparison between early surgery combined hematoma evacuation (within 24 hours of randomization) with medical treatment. . Mendelow AD. Gregson BA.3% (–3.89.7). Shaw MD. Of 468 patients randomized to early surgery. Barer DH. Hope DT. At 6 months.414). Fernandes HM. STICH investigators. and 17 were alive with unknown status. P . FINDINGS: A total of 1. Karimi A. absolute benefit 2. Murray GD.033 patients from 83 centers in 27 countries were randomized to early surgery (503) or initial conservative treatment (530).19.365:387–97.

Treatment The results of SICHPA trial ( Stereotatactic Treatment of Intracerebral Haematoma by means of a Plasminogen Activator  The trial was prematurely stopped because of low recruitment. A cautious conclusion could be made that stereotactic aspiration of supratentorial hematoma after instillation of a plasminogen activator can be performed safely.Management . It may reduce the hematoma volume significantly .

and improved clinical outcome significantly.Treatment Main results of Novo-7 trial   Treatment with rFVIIa within 4 hours reduced hematoma expansion. 80 ug/kg – Within 4 hour of ictus . decreased mortality. despite slight increase in the risk of thromboembolic events. A phase III trial is needed to confirm the beneficial effect of rFVIIa in acute ICH – FAST trial – phase 3 – Doses 20.Management .

Criteria for surgery      Age Hematoma Volume Location (Supra / Infratentorial) Progression Timing of surgery .

1989)  <60 years old 25%  >60 years old 65% The relationship between age and outcome more pronounced with thalamic hemarrhage10 Patients with ―rapidly progressive*‖ hematoma by serial CT scan.Age     Predictive role in outcome and mortality rate in patients with ICH10 Age older than 60 years implies poor prognosis regardless of treatment – Mortality rate (surgically treated): (Auer LM et al. age older than 65 years was associated with 100% mortality10 • Patients who were obtunded or stuporous without herniation signs Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 10Youmans . J Neurosurgery.

Hematoma Volume   Volume of hematoma based on CT scan measurement is a strong predictor of functional outcome and death. Duldner JE. 1993 Mortality Deep Lobar <30cm3 23% 7% 3060cm3 64% 60% >60cm3 93% 71% 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . Brott TG. Stroke 24:987-993. et al: Volume of ICH: A powerful and easy-to-use predictor of 30-day mortality.10 [Volume = 4/3 x Π x LWH ÷ 8 or LWH ÷ 2] Broderick et JP.

all cerebellar hematoma greater than 3 cm in diameter is recommended for surgery10 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . – those with hematoma volume >85cm3 have 100% mortality irrespective of treatment – Those with hematoma volume <26cm3.Hematoma Volume    Volpin et al. all survived without surgery Large-volume thalamic hematoma are more devastating than similar sized subcortical or putaminal hematomas10 For infratentorial hematoma. Neurosurgery (1984) retrospective reviewed of 132 patients with supratentorial ICH.

new IVH or metabolic abnormality.no significant difference in outcome based on treatment Fulminant = comatose. Patients’ clinical severity at 6 hours most accurately represented the severity of the ictus: – Fulminant . hydrocephalus.Progression    Broderick et al (1993) and Fujitsu K et al (1990) found that rehemorrhage typically occurs within the first 6 hours of the primary ictus Deterioration occur later than 6 hours after hemorrhage can be contributed by other factors such as edema. obtunded.outcome improved with hematoma evacuation – Slowly progressive .Poor outcome despite treatment – Rapidly progressive . herniation signs Slowly progressive = lethargy at 6 hours .

earlier interventions would intuitively appear superior Early evacuation of hematoma improves CBF. It is supported by the following facts: – 50% death of patient with ICH occur within 48 hours of hemorrhage – Radiographic expansion or rebleeding occurs maximally within 3-4 hours – Exacerbation occurs suddenly and most often within 4 to 6 hours of bleeding – Secondary changes such as edema occur 7 to 8 hours after a hemorrhage . brain edema. and outcome. ischemia.Timing of Surgery    In the case of spontaneous ICH.

Stroke.Timing of Surgery  Brott T et al. 1997. Early hemorrhage expansion is common. ~1/3 of patients who present within 3 hours of symptom onset will have substantial ICH expansion .

Surgical treatment for intracerebral hemorrhage (STICH).. . [1998] are 2 pilot studies suggested a benefit with early surgery (<12 hours) but were limited by small numbers. DUMONT. Grotta JC.D.. NEAL F. Update on management of intracerebral hemorrhage.D. 2003.D. Pasteur W. Morgenstern and colleagues[2001] showed that ultra-early surgery (that is. NADER POURATIAN.2 2Neurosurg Focus 15 (4):Article 2.Timing of Surgery     Kaneko and colleagues[1983] also demonstrated superior outcomes (relative to epidemiological data) when they reported a 6-month 7% mortality rate in a series of patients with 100 putaminal ICHs treated surgically within 7 hours of ictus Zuccarello M. M.D. Frankowski RF. Brott T. M. et al [1999] and Morgenstern LB.. Shedden P. Derex. M. PH. KASSELL. AND AARON S. 4 hours after ICH) is associated with increased re-hemorrhage and mortality rates A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) was stopped after interim analysis because of an increased rate of rebleeding.

NADER POURATIAN. et al [1999] and Morgenstern LB. Frankowski RF. Derex. Pasteur W. [1998] are 2 pilot studies suggested a benefit with early surgery (<12 hours) but were limited by small numbers. AND AARON S. 2003.D. Shedden P. 4 hours after ICH) is associated with increased re-hemorrhage and mortality rates A recent surgical evaluation of ultra-early evacuation of ICH (<3 hours) was stopped after interim analysis because of an increased rate of rebleeding. KASSELL. Update on management of intracerebral hemorrhage.D. M.Timing of Surgery     Kaneko and colleagues[1983] also demonstrated superior outcomes (relative to epidemiological data) when they reported a 6-month 7% mortality rate in a series of patients with 100 putaminal ICHs treated surgically within 7 hours of ictus Zuccarello M. M. Morgenstern and colleagues[2001] showed that ultra-early surgery (that is.2 2Neurosurg Focus 15 (4):Article 2. M.D. DUMONT. Surgical treatment for intracerebral hemorrhage (STICH). Brott T.. PH..D.. Grotta JC. NEAL F. .

GREGORY THOMPSON.Patient’s selection    Significant consideration for surgical intervention is given in cases involving younger patients (that is. NADER POURATIAN..D. those < 60 years of age) with superficial hemorrhages (particularly in the non-dominant hemisphere) in whom neurological status deteriorates after an initially good presentation2 Patients with relatively normal consciousness (GCS Scores 13–15) rarely require surgery. Update on management of intracerebral hemorrhage..D.. AND AARON S... FEWEL.D. M.4 Surgery is therefore usually considered to have the most potential benefit for the group of patients with GCS scores between 6 and 12 or in patients with deteriorating status4 2Neurosurg Focus 15 (4):Article 2. Spontaneous intracerebral hemorrhage: a review MATTHEW E. KASSELL. B. M.D. M.D.D. PH. DUMONT. JR. AND JULIAN T. whereas deeply comatose patients (GCS Scores 3–5) rarely benefit from surgery. 4Neurosurg Focus 15 (4):Article 1. M.D .. HOFF. 2003. M. M. 2003. NEAL F.

M. M.4 Kanaya and Kuroda [1992] recommended surgical treatment if the hematoma volume was larger than 30 ml and the level of consciousness was somnolent to semicomatose. functional outcome is not necessarily worse.D. but the effect on prognosis remains unproven.. 4Neurosurg Focus 15 (4):Article 1.D . GREGORY THOMPSON. FEWEL. Spontaneous intracerebral hemorrhage: a review MATTHEW E.Patient’s selection     There is a neurosurgical bias toward more aggressive surgery for nondominant hemispheric hemorrhages.D.4 Standard craniotomy for primary brainstem or thalamic hemorrhages has been all but abandoned because of poor outcomes4 Apparently successful cases of stereotactic aspiration of pontine hematomas have been reported. B. HOFF. AND JULIAN T.. JR. M. although the authors of outcome studies have indicated that despite language disability associated with dominant hemispheric lesions. 2003..

grade B recommendation). arteriovenous malformation. Young patients with a moderate or large lobar hemorrhage who are clinically deteriorating (levels of evidence II through V.Summary of Guidelines for Removal of ICH Nonsurgical candidates 1 . Patients with small hemorrhages (<10 cm3) or minimal neurological deficits (levels of evidence II through V. 2 . grade B recommendation). 1998 . However. Patients with cerebellar hemorrhage >3 cm who are neurologically deteriorating or who have brain stem compression and hydrocephalus from ventricular obstruction should have surgical removal of the hemorrhage as soon as possible (levels of evidence III through V. grade B recommendation). Best therapy unclear American Heart Association : Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. ICH associated with a structural lesion such as an aneurysm. 3 . grade C recommendation). or cavernous angioma may be removed if the patient has a chance for a good outcome and the structural vascular lesion is surgically accessible (levels of evidence III through V. Surgical candidates 1 . patients with a GCS score 4 who have a cerebellar hemorrhage with brain stem compression may still be candidates for lifesaving surgery in certain clinical situations. grade C recommendation). 2 . Patients with a GCS score 4 (levels of evidence II through V.

stereotactic aspiration. ranging from 20-90% Because of this. and endoscopy. In particular circumstances. mechanically assisted aspiration.Surgical Techniques      In 1903. Cushing first removed an intracerebral hematoma by craniotomy However operative mortality are high. some of these techniques may be more efficacious for deep putaminal or thalamic hemorrhages. various less invasive methods of removal are practised like simple aspiration. fibrinolytic treatment. 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . Others are beneficial for subcortical hematomas.

M.Surgical Techniques    The optimal surgical technique for hematoma evacuation is not agreed upon. allow more precise clot localization and minimization of injury to normal brain4 Compared with craniotomy. as well as intraoperative ultrasonographic guidance. FEWEL.D. 2003.D. although craniotomy remains the most common. but this has yet to be proven.4 Traditional stereotaxy or frameless navigational systems. GREGORY THOMPSON. M. B. M.D. HOFF. .... AND JULIAN T.4 4Neurosurg Focus 15 (4):Article 1. minimally invasive techniques such as stereotactic or endoscopic clot evacuation may offer the potential for a reduced incidence of surgery-related complications and improved efficacy. JR. Spontaneous intracerebral hemorrhage: a review MATTHEW E.

ie transtemporal. potential brain manipulation.Craniotomy     The most widely used surgical intervention in ICH is craniotomy and evacuation of the gross clot. and anesthesia. For putaminal hematoma. transfrontal and transsylvian. three general approaches have been used. with preferred transcisternal-transsylvian-transinsular approach. Operating microscope is used routinely with bipolar coagulation. . and graduated sucker. This is a relatively invasive procedure associated with additional risks by subjecting patients to surgery.

cryptic AVMs and carvenous angiomas All tissue is sent for histologic analysis Hemostasis is ensured by elevating systolic pressure temporarily to identify potential rebleeding sites. 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . Particular attention to bleeding points and possible subtle pathologic findings such as small tumours. The center of hematoma is removed first with the remaining marginal clot then collapses and can likewise be evacuated.Craniotomy      Avoid usage of self-retaining retractors as steady retraction is deleterious to brain parenchymal.

and a ventriculostomy if hydrocephalus. their length is minimized.Craniotomy     For large hematomas. with paramedian incision. Transtemporal approach is used if hematomas significantly extends into the temporal lobe The general surgical principles for evacuating hematomas at other locations. craniotomy rather craniectomy. a suboccipital craniotomy is standard. eloquent tissue is avoided. transcortical approaches is evocated. For infratentorial hematomas. 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . is corticotomies are placed near the epicanter of the ICH.

4% had post-operative bleeding. within one hour of clot genesis.Burr Hole Aspiration      Unpredictable consistency of hematomas makes aspiration difficult. Experiementally. 80% of the clot becomes dense fibrous tissue. noted 75% had more than 50% of the clot removed and 7. Niizuma et al (1989) study the result of stereotactic aspiration in 175 patients with putaminal hemorrhage. The low effectiveness and high rates of recurrence are major limitation. 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 . There is also a propensity to rebleed. which makes the lack of visualization risker.

Stereotactic Aspiration    First used by Benes and coworkers in 1965 with limited success and only in 1978. Backlund and Von Holst performed first successful stereotactic aspiration of an acute hemorrhage. . However. lack of direct visualization and the risk of rebleeding may limit this technique’s utility especially during the hyperacute phase of hemorrhage. It has favourable outcome than craniotomy in deep-seated lesions.

Then a Dandy ventricular catheter is placed into the hematoma bed. Niizuma et al reported a CT-guided technique of hematoma aspiration and lysis using urokinase. After localization. repeated two to four times a day in 1 to 6 days until CT documents clot ressolution. and urokinase (6000 U in 3 ml) is infused. . which dissolves fibrin.Stereotactic Aspiration and Clot Lysis      In 1985. Fibrinolysis is used to fascilitate clot dissolution by activating plasminogen. 3-4mm silicone tube is passed into the clot and hematoma is aspirated with a syringe repeatedly until no more clot is removed. Localization by direct-image projection on CT scanner with a radiopaque marker has approximately 5mm error compared to stereotaxy.

Grace MG. urokinase is cheaper..D. Infectious complications of catheter placement and fibrinolysis vary between 0 and 5%... dissolves existing clot and inhibit the formation of new clot Additional risk is rebleeding. M. longer half-life and has both fibrinolytic and fibrinogenolytic activity. JR. FEWEL. HOFF. B. M. 2003.D.4 Findlay JM. [1993] found that thrombolytic agents have also been successfully used for hemorrhage in the ventricular system 4Neurosurg Focus 15 (4):Article 1. AND JULIAN T. Weir BK. GREGORY THOMPSON. M. Spontaneous intracerebral hemorrhage: a review MATTHEW E.Stereotactic Aspiration and Clot Lysis     Compared to t-PA.D . Neurosurgery.

Class III] reported on 29 patients with IVH treated with intraventricular streptokinase or urokinase. . and there was a trend toward lower mortality. Class I] randomized 48 patients with spontaneous IVH to receive placebo or 3 mg TPA injected every 12 hours into the ventricle.Stereotactic Aspiration and Clot Lysis   Naff et al. [Neurosurgery. [Hong Kong Med J 2003 . no bleeding) and effectively (shunt rate. Clot resolution was faster in the TPA group. although bleeding complications were greater in patients receiving TPA Lee et al. 24%). and found that blood could be removed safely (infection rate 3%. 2004.

Neuroendoscpic Techniques    Endoscopy has not been used extensively to treat ICH This minimally invasive techniques designed to decrease hematoma size while limiting surgical trauma. There were no differences in outcome for putaminal or thalamic hemorrhage. The procedure was associated with good outcome where evacuation more than 50% in all patients with 45% patients with more than 70% clot evacuated. In a study with 6 mm diameter neuroendoscope which was placed through a burr hole and guided by intraoperative ultrasonography. 10Youmans Neurological Surgery Fifth Edition Volume 2 : Chapter 105 pages 1733-1768 .

with the persistent benefit of reducing clot volume. Benefit may in fact be due to the reduced stress provided by this less invasive surgical procedure. neuroendoscopic navigation. Class III].atients whom underwent burr hole. Longatti PL. and aspiration of hematoma. . et al in review of 13 patients having endoscopic removal of IVH at one institution during 7 years reported safe and successful removal of blood with favorable outcome in 62% [Stroke 2004.Neuroendoscpic Techniques    Auer and colleagues (1989)found of all p. those benefit of surgery with respect to QOL was limited to patients with lobar hematomas and those younger than 60 years of age.

J Neurosurg.04) surgery better . Endoscopic surgery versus medial treatment for spontaneous intracerebral hematoma: a randomized study. 1989. et al. •50 patients surgical group •50 patients medical group •Treatment: Endoscopic aspiration of clot •Outcome: Mortality and disability at 6 months Results: Surgical Mortality Poor Outcome 42% Medical 70% 58% 74% Odds Ratio of Death and Dependency: 0.46 (0. Deinsberger W.20-1. 70: 530-535 •Inclusion Criteria: Patients with CT confirmed supratentiorial ICH > 10 cc and < 48 hours from time of onset with altered level of consciousness. Neiderkorn K.Endoscopic Aspiration for Supratentorial ICH Auer LM.

Neurology. may be considered. [1998] study the response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus in 24 patients concluded that external ventricular drains did not improve hydrocephalus. Adams RE. ICP monitoring. with the aid of either a fiberoptic intraparenchymal monitor or ventriculostomy. Diringer MN.Ventriculostomy    Comatose patients in whom neurological status is severely impaired at baseline (GCS score < 9). The advantage of the ventriculostomy is that it can also be used as a therapeutic means of reducing ICP. and changes in ventricular volume did not correlate with changes in level of alertness .

4 Several series have reported good outcomes associated with surgical evacuation for patients with cerebellar hemorrhages greater than 3 cm.. M.. 4 This agreement exists despite that fact that there are no randomized controlled trials evaluating surgical methods in posterior fossa SICH.D. GREGORY THOMPSON. . Spontaneous intracerebral hemorrhage: a review MATTHEW E. M. B. FEWEL.. M. AND JULIAN T.D. JR. HOFF.D.4 4Neurosurg Focus 15 (4):Article 1.Surgical Evacuation of Cerebellar ICH    There seems to be a general consensus regarding the role of surgery in patients with infratentorial hematomas. 2003. or with brainstem compression and hydrocephalus.

Surgical Evacuation of Cerebellar ICH    No evidence from randomized trials of benefits of surgical evacuation in ICH. 21(8) Suppl: I62. et al. Miyata A. Serizawa T. Evidence mostly in the form of case series. Stroke. 1990. Treatment of cerebellar hemorrhage—surgical or conservative. Patients with GCS < 13. Kobayaski S. 45 treated medically 30 treated with decompressive surgery. Design: Non-randomized Prospective Patients: 75 patients with cerebellar hemorrhage were studied. and hematoma > 40 mm Good outcome occurred 58% with surgery while only 18% with conservative medical therapy .

FEWEL. M. 2003.Summary of Surgical Treatment Recommendations4      Patients with small hemorrhages or minimal neurological deficit generally do well by undergoing medical treatment alone. or in whom brainstem compression and hydrocephalus are present. Spontaneous intracerebral hemorrhage: a review MATTHEW E. Ultra-early removal of the hematoma by localized minimally invasive surgical procedures is promising but unproven. .. AND JULIAN T.or largesized lobar hemorrhages. 4Neurosurg Focus 15 (4):Article 1. M.D. those with large-sized basal ganglia hemorrhages. and those exhibiting progressive neurological deterioration. Elderly patients in whom the GCS score is less than 5 and those with brainstem hemorrhages also do not typically benefit from surgery Patients with cerebellar hemorrhages greater than 3 cm in whom are symptoms or neurological deterioration have occurred. M.D.D. should undergo evacuation of the clot. HOFF.. B. Evacuation should be considered in patients with moderate. GREGORY THOMPSON.. JR.

ICH Evaluation and Treatment .

the development of cerebral edema. tight glucose control. approach. Mayer SA [2003] has suggested there may be a role for ultra-early hemostatic therapy with recombinant factor VIIa to prevent further hematoma expansion. Best medical management has yet to be defined and may include future treatments of blood pressure and hypothermia. and selected use of glucocorticoids. Results from the STICH have provided important information about the utility of surgical evacuation of ICH but do not address questions about the timing. . and the identity of hemoglobin degradation neurotoxins will lead to more focused pharmacological treatments.FUTURE DIRECTIONS     With the improved understanding of the pathophysiological changes that result in hematoma expansion. and technique of other procedures.

FUTURE DIRECTIONS Stem cell therapy    After the clot is removed. These animals had better motor function compared with control subjects . stroke. 2003) Nonaka M. had human neural stem cells were injected intravenously 1 day after experimental ICH in rats. et al. Transplanted neural human stem cells have been shown to improve functional recovery in an animal model of ICH (Jeong SW. stem cells had migrated to the perihematomal region where they differentiated into neurons and astrocytes. After 2 months.(Neurol Res 2004). there is possibility of improving functional outcome by using stem cells to restore the damaged cerebral architecture.

Hemostatic Therapy: Future?    The lack of surgery-related benefit may suggest that clot evacuation after hematoma expansion is not beneficial. Hemostatic therapy. to modify the evolution of the hematoma Much attention has been given to factor VIIa. which promotes local hemostasis at sites of vascular injury in patients with and without coagulopathies. . is intended to stimulate clotting in individuals in whom the coagulation cascade is otherwise normal. however.

Level of evidence Level I Level II Level III Level IV Level V Strength of recommendation Grade A Supported by Level I evidence Data from randomized trials with low false-positive ( ) and low false-negative (ß) errors Data from randomized trials with high false-positive ( ) or high false-negative (ß) errors Data from nonrandomized concurrent cohort studies Data from nonrandomized cohort studies using historical controls Data from anecdotal case series Grade B Grade C Supported by Level II evidence Supported by Levels III through V evidence .

Thank You .