Emergency Neurological Life Support: Intracerebral Hemorrhage

Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage: A propensity-matched analysis

BACKGROUND

Minimally invasive surgery (MIS) and craniotomy (CI) are the current treatments for spontaneous supratentorial cerebral haemorrhage (SSTICH).

AIM

To compare the efficacy and safety of MIS and CI for the treatment of SSTICH.

METHODS

Clinical and imaging data of 557 consecutive patients with SSTICH who underwent MIS or CI between January 2017 and December 2022 were retrospectively analysed. The patients were divided into two subgroups: The MIS group and CI group. Propensity score matching was performed to minimise case selection bias. The primary outcome was a dichotomous prognostic (favourable or unfavourable) outcome based on the modified Rankin Scale (mRS) score at 3 months; an mRS score of 0–2 was considered favourable.

RESULTS

In both conventional statistical and binary logistic regression analyses, the MIS group had a better outcome. The outcome of propensity score matching was unexpected (odds ratio: 0.582; 95%CI: 0.281–1.204; P = 0.144), which indicated that, after excluding the interference of each confounder, different surgical modalities were more effective, and there was no significant difference in their prognosis.

CONCLUSION

Deciding between MIS and CI should be made based on the individual patient, considering the hematoma size, degree of midline shift, cerebral swelling, and preoperative Glasgow Coma Scale score.

PHE-SICH-CT-IDS: A benchmark CT image dataset for evaluation semantic segmentation, object detection and radiomic feature extraction of perihematomal edema in spontaneous intracerebral hemorrhage

BACKGROUND AND OBJECTIVE

Intracerebral hemorrhage is one of the diseases with the highest mortality and poorest prognosis worldwide. Spontaneous intracerebral hemorrhage (SICH) typically presents acutely, prompt and expedited radiological examination is crucial for diagnosis, localization, and quantification of the hemorrhage. Early detection and accurate segmentation of perihematomal edema (PHE) play a critical role in guiding appropriate clinical intervention and enhancing patient prognosis. However, the progress and assessment of computer-aided diagnostic methods for PHE segmentation and detection face challenges due to the scarcity of publicly accessible brain CT image datasets.

METHODS

This study establishes a publicly available CT dataset named PHE-SICH-CT-IDS for perihematomal edema in spontaneous intracerebral hemorrhage. The dataset comprises 120 brain CT scans and 7,022 CT images, along with corresponding medical information of the patients. To demonstrate its effectiveness, classical algorithms for semantic segmentation, object detection, and radiomic feature extraction are evaluated. The experimental results confirm the suitability of PHE-SICH-CT-IDS for assessing the performance of segmentation, detection and radiomic feature extraction methods.

RESULTS

This study conducts numerous experiments using classical machine learning and deep learning methods, demonstrating the differences in various segmentation and detection methods on the PHE-SICH-CT-IDS. The highest precision achieved in semantic segmentation is 76.31%, while object detection attains a maximum precision of 97.62%. The experimental results on radiomic feature extraction and analysis prove the suitability of PHE-SICH-CT-IDS for evaluating image features and highlight the predictive value of these features for the prognosis of SICH patients.

CONCLUSION

To the best of our knowledge, this is the first publicly available dataset for PHE in SICH, comprising various data formats suitable for applications across diverse medical scenarios. We believe that PHE-SICH-CT-IDS will allure researchers to explore novel algorithms, providing valuable support for clinicians and patients in the clinical setting. PHE-SICH-CT-IDS is freely published for non-commercial purpose at https://figshare.com/articles/dataset/PHE-SICH-CT-IDS/23957937.

Medical versus neurosurgical treatment in ICH patients: a single center experience

BACKGROUND AND AIMS

The effect of surgical treatment for spontaneous intracerebral hemorrhage (ICH) remains uncertain. We conducted an observational retrospective cohort study on supra-centimeter spontaneous ICH treated with either neurosurgical or conservative management. The baseline demographics and risk factors were correlated with in-hospital mortality and 3 and 6-month survival rates stratified by management.

METHODS

We included all patients with evidence of spontaneous ICH > 1 cm detected by CT and admitted between august 2020 and march 2021 to the "SMM" Hospital in Perugia.

RESULTS

Onehundredandtwentytwo patients were included in the study, and 45% (n.55) were surgically treated. The mean age was 71.9 ± 15.3, and 61% (n.75) were males. Intra-hospital mortality ended up being 31% (n.38), 3 months-survival was 63% (n.77) and 6 months-survival was 60% (n.73). From the multivariate analysis of the surgical patients versus medical patient, we observed that the surgical patients were younger (67.5 ± 14.9 vs 75.5 ± 14.7 y; OR 0.87; Cl 95% 0.85-0.94; p 0.001), with greater ICH volume at the onset (61 ± 39.4 cc vs 51 ± 64 cc; OR 1.03; Cl 95% 1.005-1.07; p 0.05), more midline shift (7.61 ± 5.54 mm vs 4.09 ± 5.88 mm; OR 1.37; Cl 95% 1.045-1.79; p 0.023), and a higher ICH score (3 vs 2 mean ICH score; OR 21.12; Cl 95% 2.6-170.6; p 0.004). Intra-hospital mortality in the surgical group and in the conservative treatment group was respectively 33% vs 30%, 3 month-survival was 64% vs 63% and 6 month- survival were 60% in both groups.

CONCLUSIONS

Our patient cohort shows no overall benefit from surgery over conservative treatment, but surgical patients were younger and had larger ICH volume.

Outcome Prediction of Spontaneous Supratentorial Intracerebral Hemorrhage after Surgical Treatment Based on Non-Contrast Computed Tomography: A Multicenter Study

This study aims to explore the value of a machine learning (ML) model based on radiomics features and clinical features in predicting the outcome of spontaneous supratentorial intracerebral hemorrhage (sICH) 90 days after surgery. A total of 348 patients with sICH underwent craniotomy evacuation of hematoma from three medical centers. One hundred and eight radiomics features were extracted from sICH lesions on baseline CT. Radiomics features were screened using 12 feature selection algorithms. Clinical features included age, gender, admission Glasgow Coma Scale (GCS), intraventricular hemorrhage (IVH), midline shift (MLS), and deep ICH. Nine ML models were constructed based on clinical feature, and clinical features + radiomics features, respectively. Grid search was performed on different combinations of feature selection and ML model for parameter tuning. The averaged receiver operating characteristics (ROC) area under curve (AUC) was calculated and the model with the largest AUC was selected. It was then tested using multicenter data. The combination of lasso regression feature selection and logistic regression model based on clinical features + radiomics features had the best performance (AUC: 0.87). The best model predicted an AUC of 0.85 (95%CI, 0.75-0.94) on the internal test set and 0.81 (95%CI, 0.64-0.99) and 0.83 (95%CI, 0.68-0.97) on the two external test sets, respectively. Twenty-two radiomics features were selected by lasso regression. The second-order feature gray level non-uniformity normalized was the most important radiomics feature. Age is the feature with the greatest contribution to prediction. The combination of clinical features and radiomics features using logistic regression models can improve the outcome prediction of patients with sICH 90 days after surgery.

Risk factors for poor outcomes of spontaneous supratentorial cerebral hemorrhage after surgery

OBJECTIVE

This study aimed to explore the factors affecting the outcomes of spontaneous supratentorial cerebral hemorrhage 90 days after surgery.

METHODS

A total of 256 patients with spontaneous supratentorial intracerebral hemorrhage underwent craniotomy evacuation of hematoma. The control group included 120 patients who received conservative treatment. The patients were divided into two subgroups based on a bifurcation of the modified Rankin Scale (mRS) 90 days after clinical therapeutics: good outcome (mRS score 0-3) and poor outcome (mRS score 4-6). The differences in clinical and imaging data between the two subgroups were analyzed. Based on difference analysis results, a binary logistic regression model was constructed to analyze the influencing factors related to poor outcomes.

RESULTS

The difference analysis results in the surgery group showed statistically significant differences in age, sex, Glasgow Coma Score (GCS) on admission, coronary atherosclerosis, smoking, stroke history, blood glucose, D-dimer, hematoma size, deep cerebral hemorrhage, midline shift, hematoma burst into the ventricle, vortex sign, island sign, and black hole sign. Binary logistic regression analysis showed that deep cerebral hemorrhage, midline shift, and age > 58 years independently correlated with the poor outcomes of patients after surgery. The binary logistic regression results of the control group showed that age > 58 years and GCS ≤ 8 independently correlated with the poor outcomes of patients.

CONCLUSIONS

Deep cerebral hemorrhage, midline shift, and age > 58 years significantly increased the risk of adverse prognosis in patients after surgery. The findings might help select the clinical treatment plan and evaluate the postoperative prognosis of patients.

Intracerebral hemorrhage: update and future directions

Intracerebral hemorrhage (ICH), defined as bleeding into the brain parenchyma, is a significant public health issue. Although it accounts for only 10 to 15% of strokes, it is associated with the highest morbidity and mortality rates. Despite advances in the field of stroke and neurocritical care, the principles of acute management have fundamentally remained the same over many years. The main treatment strategies include aggressive blood pressure control, early hemostasis, reversal of coagulopathies, clot evacuation through open surgical or minimally invasive surgical techniques, and the management of raised intracranial pressure.

Surgery for spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. 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.

Several surgical techniques have been considered, such as open craniotomy, decompressive craniectomy, neuroendoscopy, and minimally invasive catheter evacuation followed by thrombolysis. Open craniotomy is the most studied approach in this clinical scenario, the first randomized controlled trial dating from the early 1960s. Since then, a large number of studies have been published, which included two large, well-designed, well-powered, multicenter, multinational, randomized clinical trials. These studies, The International Surgical Trial in Intracerebral Hemorrhage (STICH), and the STICH II have shown no clinical benefit for early surgical evacuation of intraparenchymal hematoma in patients with spontaneous supratentorial hemorrhage when compared with best medical management plus delayed surgery if necessary. However, the results of STICH trials may not be generalizable, because of the high rates of patients’ crossover from medical management to the surgical group. Without these high crossover percentages, the rates of unfavorable outcome and death with conservative management would have been higher. Additionally, comatose patients and patients at risk of cerebral herniation were not included. In these cases, surgery may be lifesaving, which prevented those patients of being enrolled in such trials. This article reviews the clinical evidence of surgical hematoma evacuation, and its role to decrease mortality and improve long-term functional outcome after spontaneous intracerebral hemorrhage.

Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management

PURPOSE OF REVIEW

Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated.

RECENT FINDINGS

The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.

Management of neurologic complications of coagulopathies

Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.