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Blanco-Acevedo C, Aguera-Morales E, Fuentes-Fayos AC, Pelaez-Viña N, Diaz-Pernalete R, Infante-Santos N, Muñoz-Jurado A, Porras-Pantojo MF, Ibáñez-Costa A, Luque RM, Solivera-Vela J. Decompressive Hemicraniectomy without Evacuation of Acute Intraparenchymal Hemorrhage. Biomedicines 2024; 12:1666. [PMID: 39200131 PMCID: PMC11352014 DOI: 10.3390/biomedicines12081666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Intracerebral hemorrhages (ICHs) are prevalent, with high morbidity and mortality. We analyzed whether decompressive craniectomy (DC) without evacuation of the acute intraparenchymal hematoma could produce better functional outcomes than treatment with evacuation. METHODS Patients with acute ICH treated with DC without clot evacuation, or evacuation with or without associated craniectomy were included. Matched univariate analyses were performed, and a binary logistic regression model was constructed using the Glasgow Outcome Scale (GOS) and modified Rankin scale (mRS) as dependent variables. RESULTS 27 patients treated with DC without clot evacuation were compared to 36 patients with clot evacuation; eleven of the first group were matched with 18 patients with evacuation. A significantly better functional prognosis in the group treated with DC without clot evacuation was found. Patients aged < 55 years and treated with DC without clot evacuation had a significantly better functional prognosis (p = 0.008 and p = 0.039, respectively). In multivariate analysis, the intervention performed was the greatest predictor of functional status at the end of follow-up. CONCLUSIONS DC without clot evacuation improves the functional prognosis of patients with acute intraparenchymal hematomas. Larger multicenter studies are warranted to determine whether a change in the management of acute ICH should be recommended.
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Affiliation(s)
- Cristóbal Blanco-Acevedo
- Department of Neurosurgery and Neurology, Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain; (E.A.-M.); (N.P.-V.); (J.S.-V.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
| | - Eduardo Aguera-Morales
- Department of Neurosurgery and Neurology, Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain; (E.A.-M.); (N.P.-V.); (J.S.-V.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
| | - Antonio C. Fuentes-Fayos
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14014 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Nazareth Pelaez-Viña
- Department of Neurosurgery and Neurology, Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain; (E.A.-M.); (N.P.-V.); (J.S.-V.)
| | - Rosa Diaz-Pernalete
- Intensive Care Service, Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain; (R.D.-P.)
| | | | - Ana Muñoz-Jurado
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14014 Cordoba, Spain
| | | | - Alejandro Ibáñez-Costa
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14014 Cordoba, Spain
| | - Raúl M. Luque
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 14014 Cordoba, Spain
- CIBER Physiopathology of Obesity and Nutrition (CIBERobn), 14004 Cordoba, Spain
| | - Juan Solivera-Vela
- Department of Neurosurgery and Neurology, Reina Sofia University Hospital (HURS), 14004 Cordoba, Spain; (E.A.-M.); (N.P.-V.); (J.S.-V.)
- Maimonides Institute of Biomedical Research of Cordoba (IMIBIC), Reina Sofia University, Hospital University of Cordoba, 14004 Cordoba, Spain; (A.C.F.-F.); (A.M.-J.); (A.I.-C.); (R.M.L.)
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
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Schröder I, Güresir E, Vatter H, Soehle M. Single-centre real-life observational study on mortality and outcomes: decompressive craniectomy and brain death in traumatic brain injury, haemorrhage, and other cerebral diseases. Acta Neurochir (Wien) 2024; 166:283. [PMID: 38969875 PMCID: PMC11226498 DOI: 10.1007/s00701-024-06170-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/12/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is used after severe brain damages with elevated, refractory intracranial pressure (ICP). In a non age-restricted population, mortality rates and long-term outcomes following DHC are still unclear. This study's objectives were to examine both, as well as to identify predictors of unfavourable outcomes. METHODS We undertook a retrospective observational analysis of patients aged 18 years and older who underwent DHC at the University Hospital of Bonn between 2018 and 2020, due to traumatic brain injury (TBI), haemorrhage, tumours or infections. Patient outcomes were assessed by conducting telephone interviews, utilising questionnaires for modified Rankin Scale (mRS) and extended Glasgow Outcome scale (GOSE). We evaluated the health-related quality of life using the EuroQol (EQ-5D-5L) scale. RESULTS A total of 144 patients with a median age of 58.5 years (range: 18 to 85 years) were evaluated. The mortality rate was 67%, with patients passing away at a median of 6.0 days (IQR [1.9-37.6]) after DHC. Favourable outcomes, as assessed by the mRS and GOSE were observed in 10.4% and 6.3% of patients, respectively. Cox regression analysis revealed a 2.0% increase in the mortality risk for every year of age (HR = 1.017; 95% CI [1.01-1.03]; p = 0.004). Uni- and bilateral fixed pupils were associated with a 1.72 (95% CI [1.03-2.87]; p = 0.037) and 3.97 (95% CI [2.44-6.46]; p < 0.001) times higher mortality risk, respectively. ROC-analysis demonstrated that age and pupillary reactivity predicted 6-month mortality with an AUC of 0.77 (95% CI [0.69-0.84]). The only parameter significantly associated with a better quality of life was younger age. CONCLUSIONS Following DHC, mortality remains substantial, and favourable outcomes occur rarely. Particularly in elderly patients and in the presence of clinical signs of herniation, mortality rates are notably elevated. Hence, the indication for DHC should be set critically.
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Affiliation(s)
- Isabelle Schröder
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Martin Soehle
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Oehmichen M, Woischneck D, Mayer B, Pala A. Outcome after Intracerebral Haemorrhage and Decompressive Craniectomy in Older Adults. Neurol Int 2024; 16:590-604. [PMID: 38804483 PMCID: PMC11130851 DOI: 10.3390/neurolint16030044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE There is a relationship between the incidence of spontaneous intracerebral haemorrhage (ICH) and age. The incidence increases with age. This study aims to facilitate the decision-making process in the treatment of ICH. It therefore investigated the outcome after ICH and decompressive craniectomy (DC) in older adults (>65 years of age). METHODS Retrospective, multicentre, descriptive observational study including only consecutive patients who received DC as the consequence of ICH. Additive evacuation of ICH was performed after the individual decision of the neurosurgeon. Besides demographic data, clinical outcomes both at discharge and 12 months after surgery were evaluated according to the Glasgow Outcome Scale (GOS). Patients were divided into age groups of ≤65 and >65 years and cohorts with favourable outcome (GOS IV-V) and unfavourable outcome (GOS I to III). RESULTS 56 patients were treated. Mean age was 53.3 (SD: 16.13) years. There were 41 (73.2%) patients aged ≤65 years and 15 (26.8%) patients aged >65 years. During hospital stay, 10 (24.4%) patients in the group of younger (≤65 years) and 5 (33.3%) in the group of older patients (>65 years) died. Mean time between ictus and surgery was 44.4 (SD: 70.79) hours for younger and 27.9 (SD: 41.71) hours for older patients. A disturbance of the pupillary function on admission occurred in 21 (51.2%) younger and 2 (13.3%) older patients (p = 0.014). Mean arterial pressure was 99.9 (SD: 17.00) mmHg for younger and 112.9 (21.80) mmHg in older patients. After 12 months, there was no significant difference in outcome between younger patients (≤65 years) and older patients (>65 years) after ICH and DC (p = 0.243). Nevertheless, in the group of younger patients (≤65 years), 9% had a very good and 15% had a good outcome. There was no good recovery in the group of older patients (>65 years). CONCLUSION Patients >65 years of age treated with microsurgical haematoma evacuation and DC after ICH are likely to have a poor outcome. Furthermore, in the long term, only a few older adults have a good functional outcome with independence in daily life activities.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Stefanie Jesuthasan
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Frederike Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Franziska Schiller
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Marcel Oehmichen
- Department of Neurosurgery, Military Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Dieter Woischneck
- Department of Neurosurgery, Hospital Landshut, Robert-Koch-Strasse 1, 84034 Landshut, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Schwabstrasse 13, 89075 Ulm, Germany
| | - Andrej Pala
- Department of Neurosurgery, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Johnson WC, Ravindra VM, Fielder T, Ishaque M, Patterson TT, McGinity MJ, Lacci JV, Grandhi R. Surface Area of Decompressive Craniectomy Predicts Bone Flap Failure after Autologous Cranioplasty: A Radiographic Cohort Study. Neurotrauma Rep 2021; 2:391-398. [PMID: 34901938 DOI: 10.1089/neur.2021.0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Skull bone graft failure is a potential complication of autologous cranioplasty after decompressive craniectomy (DC). Our objective was to investigate the association of graft size with subsequent bone graft failure after autologous cranioplasty. This single-center retrospective cohort study included patients age ≥18 years who underwent primary autologous cranioplasty between 2010 and 2017. The primary outcome was bone flap failure requiring graft removal. Demographic, clinical, and radiographic factors were recorded; three-dimensional (3D) reconstructive imaging was used to perform accurate measurements. Univariate and multi-variate regression analysis were performed to identify risk factors for the primary outcome. Of the 131 patients who underwent primary autologous cranioplasty, 25 (19.0%) underwent removal of the graft after identification of bone flap necrosis on computed tomography (CT); 16 (64%) of these were culture positive. The mean surface area of craniectomy defect was 128.5 cm2 for patients with bone necrosis and 114.9 cm2 for those without bone necrosis. Linear regression analysis demonstrated that size of craniectomy defect was independently associated with subsequent bone flap failure; logistic regression analysis demonstrated a defect area >125 cm2 was independently associated with failure (odds ratio [OR] 3.29; confidence interval [CI]: 0.249-2.135). Patient- and operation-specific variables were not significant predictors of bone necrosis. Our results showed that increased size of antecedent DC is an independent risk factor for bone flap failure after autologous cranioplasty. Given these findings, clinicians should consider the increased potential of bone flap failure after autologous cranioplasty among patients whose initial DC was >125 cm2.
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Affiliation(s)
- W Chase Johnson
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, California, USA.,Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Tristan Fielder
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Mariam Ishaque
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - T Tyler Patterson
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Michael J McGinity
- Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - John V Lacci
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Shaaban A, Saqqur M, Saleh A, Ahmed A, Hussain H, Babu R A, Alyafai A, Belkhair S, Ayyad A. Retrospective analysis of the surgical management of spontaneous supratentorial intracerebral hemorrhage: A single-center study. Qatar Med J 2021; 2021:53. [PMID: 34712600 PMCID: PMC8525251 DOI: 10.5339/qmj.2021.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Intracerebral hemorrhage (ICH) remains a devastating disease with high morbidity and mortality. The mortality rate ranges from 40% at 1 month to 54% at 1 year, and only 12%–39% achieve good outcomes and functional independence. The current management guidelines for spontaneous supratentorial ICH are still controversial. Objective: Patients who presented with ICH and underwent craniotomy with hematoma evacuation or minimal procedures from January 2016 to May 2020 were included in the analysis. Several clinical, radiological, and surgical variables were collected to identify the variables most likely related to lower mortality and better functional outcomes. Results: A total of 87 patients presented with HMC with ICH from January 2016 to May 2020. The mean age was 44.7 (42.2–47.2) years. There were 76 male (87.4%)/11 female (12.6%) patients, which reflect the population distribution in Qatar, which is mainly male predominant. Although Qatar is mainly a Middle-Eastern country, the ethnic distribution of patients was mainly of South Asian and Indian (60.9%) and Far-Eastern (20.7%) ethnicities because of diversity. The mean baseline Glasgow coma scale (GCS) was 8.2+/ − 3.7. The mean baseline functional independence measure (FIM) score was 59.4+/ − 36.7. Most hematomas were located in the basal ganglia (79.3%%). Baseline characteristics based on long-term outcomes are summarized in Table 1. The following variables were correlated with poor outcome: low GCS on postoperative day 1 (P = 0.06), low FIM score (P = 0.006), ICH location (P = 0.04), distance of the closest point to the surface (P = 0.009), and presence of uncal herniation (P = 0.04). The baseline characteristics based on mortality are outlined in Table 2. The following variables were correlated with mortality: diabetes mellitus (P = 0.02), baseline GCS (P = 0.04), GCS on postoperative day 1 (P = 0.002), unequal pupils (P = 0.05), and postoperative midline shift (P = 0.001). Conclusion: The preoperative clinical neurological status as well as mass effect (uncal herniation and midline shift) can be determinants of functional outcome and mortality. A deeper hematoma may result in poor functional outcome because of more surgical damage in functional brain tissues. Thus, the goal of surgery in spontaneous supratentorial ICH is to reduce mortality, but no evidence support that it can improve functional outcome. Although our findings are interesting, more prospective studies with a larger sample size are needed to confirm our results.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Maher Saqqur
- Department of Medicine Division of Neurology, University of Alberta, Edmonton, Alberta, Canada.,Trillium Hospital University of Toronto Mississauga, Ontario, Canada
| | - Ahmed Saleh
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Alaaeldin Ahmed
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Hussain Hussain
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
| | - Arun Babu R
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar. E-mail:
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Scullen T, Mathkour M, Werner C, Nerva JD, Dumont AS. Commentary: Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials. Oper Neurosurg (Hagerstown) 2021; 20:E33-E34. [PMID: 33316811 DOI: 10.1093/ons/opaa311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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8
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Scullen T, Mathkour M, Dumont AS. Commentary: Intracerebral Hemorrhage Volume Reduction and Timing of Intervention Versus Functional Benefit and Survival in the MISTIE III and STICH Trials. Neurosurgery 2021; 88:E391-E393. [PMID: 33555013 DOI: 10.1093/neuros/nyab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/11/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
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9
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Li L, Molian VA, Seaman SC, Zanaty M, Howard MA, Greenlee JD, Hasan DM, Leira EC. Impact of Intracerebral Hematoma Evacuation During Decompressive Hemicraniectomy on Functional Outcomes. Stroke 2021; 52:1105-1108. [PMID: 33504184 DOI: 10.1161/strokeaha.120.032224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Decompressive hemicraniectomy has been used to treat spontaneous intracerebral hemorrhage, but the benefit of evacuating the hematoma during the procedure is unclear. We aim to evaluate the utility of performing clot evacuation during hemicraniectomy for spontaneous intracerebral hemorrhage. METHODS Retrospective cohort of consecutive patients (2010-2019) treated with decompressive hemicraniectomy for a spontaneous supratentorial intracerebral hemorrhage at the University of Iowa. We compared hemicraniectomy alone to hemicraniectomy plus hematoma evacuation. We analyzed clinical features and hematoma characteristics. The outcomes at 6 months were dichotomized into unfavorable (Glasgow Outcome Scale score 1-3) and favorable (Glasgow Outcome Scale score 4-5). RESULTS Eighty-three patients underwent decompressive hemicraniectomy for spontaneous intracerebral hemorrhage, 52 with hematoma evacuation, and 31 without hematoma evacuation. There were no statistically significant differences in clinical and radiographic characteristics between the 2 groups. Evacuating the hematoma in addition to hemicraniectomy did not change the odds of favorable outcome at 6 months (P=0.806). CONCLUSIONS In this retrospective study, the performance of hematoma evacuation during decompressive hemicraniectomy for spontaneous intracerebral hemorrhage may not change functional outcomes over performing the hemicraniectomy alone.
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Affiliation(s)
- Luyuan Li
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Vaelan A Molian
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Scott C Seaman
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Mario Zanaty
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Matthew A Howard
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Jeremy D Greenlee
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - David M Hasan
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa
| | - Enrique C Leira
- Department of Neurosurgery (L.L., V.A.M., S.C.S., M.Z., M.A.H., J.D.G., D.M.H., E.C.L.), University of Iowa.,Department of Neurology (E.C.L.), University of Iowa.,Department of Epidemiology (E.C.L.), University of Iowa
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10
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Management of Intracerebral Hemorrhage: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1819-1831. [PMID: 32299594 DOI: 10.1016/j.jacc.2019.10.066] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.
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McGurgan IJ, Ziai WC, Werring DJ, Al-Shahi Salman R, Parry-Jones AR. Acute intracerebral haemorrhage: diagnosis and management. Pract Neurol 2020; 21:practneurol-2020-002763. [PMID: 33288539 PMCID: PMC7982923 DOI: 10.1136/practneurol-2020-002763] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 12/11/2022]
Abstract
Intracerebral haemorrhage (ICH) accounts for half of the disability-adjusted life years lost due to stroke worldwide. Care pathways for acute stroke result in the rapid identification of ICH, but its acute management can prove challenging because no individual treatment has been shown definitively to improve its outcome. Nonetheless, acute stroke unit care improves outcome after ICH, patients benefit from interventions to prevent complications, acute blood pressure lowering appears safe and might have a modest benefit, and implementing a bundle of high-quality acute care is associated with a greater chance of survival. In this article, we address the important questions that neurologists face in the diagnosis and acute management of ICH, and focus on the supporting evidence and practical delivery for the main acute interventions.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Wendy C Ziai
- Division of Brain Injury Outcomes, Department of Neurology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, UCL, London, UK
| | | | - Adrian R Parry-Jones
- Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
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Chakravarthi SS, Lyons L, Orozco AR, Verhey L, Mazaris P, Zacharia J, Singer JA. Combined Decompressive Hemicraniectomy and Port-Based Minimally Invasive Parafascicular Surgery for the Treatment of Subcortical Intracerebral Hemorrhage: Case Series, Technical Note, and Review of Literature. World Neurosurg 2020; 146:e1226-e1235. [PMID: 33271377 DOI: 10.1016/j.wneu.2020.11.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a neurosurgical emergency. Combined decompressive hemicraniectomy (DHC) and minimally invasive parafascicular surgery (MIPS) may provide a practical method of managing subcortical ICH. OBJECTIVE 1) To present a case series of combined DHC-MIPS for the treatment of subcortical-based ICH; 2) to describe technical nuances of DHC-MIPS; and 3) to provide a literature overview of MIPS for ICH. METHODS The following inclusion criteria were used: 1) Glasgow Coma Scale (GCS) score <3-4; 2) admission within 6 hours of onset; 3) increased intracranial pressure caused by hemorrhage; 4) patient unresponsive to medical management; 5) hemorrhage >30 cm3; 6) subcortical location; and 7) midline shift (mm). Before DHC, sulcal cannulation used the following coordinates: intersection of tragus-frontal bone and midpoint of midpupillary line and midline; coronal suture: 3-4 cm posterior to this point). RESULTS Three patients were selected: a 62-year old woman, a 45-year old woman, and a 36-year-old man. GCS and ICH scores on admission were 7 and 3, 3 and 4, and 3 and 4, respectively. ICH was located in left basal ganglia in patients 1 and 3 and right basal ganglia in patient 2, all with intraventricular extension. ICH volume was 81.7, 68.2, and 42.3 cm3, respectively. The postoperative GCS score was 11, 10, and 6, respectively. There were no intraoperative complications or mortalities. Evacuation was within 15 minutes in all patients. The modified Rankin Scale score was 3, 4, and 5, respectively, with semi-independence in case 1. CONCLUSIONS Combined DHC-MIPS, with the use of craniometric points, can provide a unique and simple surgical option for the management of subcortical ICH.
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Affiliation(s)
- Srikant S Chakravarthi
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leah Lyons
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Andres Restrepo Orozco
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Leonard Verhey
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Paul Mazaris
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Joseph Zacharia
- Department of Neurocritical Care, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA
| | - Justin A Singer
- Department of Neurosurgery, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.
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Al-Kawaz MN, Hanley DF, Ziai W. Advances in Therapeutic Approaches for Spontaneous Intracerebral Hemorrhage. Neurotherapeutics 2020; 17:1757-1767. [PMID: 32720246 PMCID: PMC7851203 DOI: 10.1007/s13311-020-00902-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (ICH) results in high rates of morbidity and mortality, with intraventricular hemorrhage (IVH) being associated with even worse outcomes. Therapeutic interventions in acute ICH have continued to emerge with focus on arresting hemorrhage expansion, clot volume reduction of both intraventricular and parenchymal hematomas, and targeting perihematomal edema and inflammation. Large randomized controlled trials addressing the effectiveness of rapid blood pressure lowering, hemostatic therapy with platelet transfusion, and other clotting complexes and hematoma volume reduction using minimally invasive techniques have impacted clinical guidelines. We review the recent evolution in the management of acute spontaneous ICH, discussing which interventions have been shown to be safe and which may potentially improve outcomes.
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Affiliation(s)
- Mais N Al-Kawaz
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Daniel F Hanley
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA
| | - Wendy Ziai
- The Johns Hopkins Hospital, 1800 Orleans Street, Phipps 455, Baltimore, MD, 21287, USA.
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14
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Rychen J, O'Neill A, Lai LT, Bervini D. Natural history and surgical management of spontaneous intracerebral hemorrhage: a systematic review. J Neurosurg Sci 2020; 64:558-570. [PMID: 32972110 DOI: 10.23736/s0390-5616.20.04940-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Management of spontaneous intracerebral hemorrhage (ICH) remains controversial despite efforts to produce high level evidence in the past few years. We systematically examined the pooled literature data on the natural history and surgical management of ICH. EVIDENCE ACQUISITION A systematic review was performed using the PubMed and Embase databases, encompassing English, full-text articles, reporting treatment outcomes for the conservative and surgical management of ICH. EVIDENCE SYNTHESIS A total of 91 studies met the eligibility criteria (total of 16,411 ICH cases). The most common locations for an ICH were the basal ganglia for both the conservative (68.7%) and surgical cohorts (58.4%). Patients in the non-operative group (40.5%) were older (mean age 62.9 years; range 12.0-94.0), had a higher Glasgow Coma Scale (GCS) score at presentation (mean GCS 10.2; range 3-15) and lower ICH volume (mean 36.9 mL). When managed non-operatively, a favorable functional outcome was encountered in 25.7% (95% CI 16.9-34.5) of patients, with a 22.2% (95% CI 16.6-27.8) mortality rate. Patients who underwent surgery (59.5%) were younger (mean age 58.8 years; range 12.0-94.0), had a lower GCS at presentation (mean GCS 8.2; range 3-15) and larger ICH volume (mean 58.3 mL; range 8.2-140.0). Craniotomy with hematoma evacuation was the preferred surgical technique (38.6%). A favorable functional outcome was encountered in 29.8% (95% CI 23.8-35.8) of operated patients, with a 21.3% (95% CI 16.3-26.3) mortality rate. CONCLUSIONS For many ICH cases, the reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH-cases where management remains controversial.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Anthea O'Neill
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | - Leon T Lai
- Department of Neurosurgery, Monash Health, Melbourne, Australia
| | - David Bervini
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland -
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Abstract
Spontaneous intracerebral hemorrhage (SICH) is a common stroke subtype, accounting for 10-35% of all stroke. It is the most disabling subtype as well, with disproportionately high rates of morbidity and mortality. Despite numerous advances in neurocritical care and stroke management, the prognosis remains poor, and no medical or surgical interventions have been shown to significantly reduce mortality or improve outcomes. Surgical evacuation of SICH has many theoretical benefits, such as reducing secondary injury, reducing intracranial pressures, and preventing cerebral herniation. However, trials involving open craniotomy for SICH evacuation have not yielded significant clinical benefit, and one thought is that benefit is not seen due to injury to the overlying healthy brain tissue. Therefore, minimally invasive options have increasingly been studied as an option to evacuate the SICH while minimizing injury to healthy tissue. We present here a select review of various minimally-invasive techniques for the evacuation of SICH.
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16
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Zhao W, Wu C, Stone C, Ding Y, Ji X. Treatment of intracerebral hemorrhage: Current approaches and future directions. J Neurol Sci 2020; 416:117020. [PMID: 32711191 DOI: 10.1016/j.jns.2020.117020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/25/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
Intracerebral hemorrhage (ICH) stands out among strokes, both for the severely morbid outcomes it routinely produces, and for the striking deficiency of defenses possessed against the same. The brain damage caused by ICH proceeds through multiple pathophysiological mechanisms, broadly differentiated into those considered primary, arising from the hematoma itself, and the secondary consequences of hematoma presence and expansion thereof. A number of interventions against ICH and its sequelae have been investigated (e.g., hemostatic therapies, blood pressure control, hematoma evacuation, and a variety of neuroprotective strategies), but conclusive demonstrations of clinical benefit have remained largely elusive. In this review, we begin with a description of these interventions and the trials in which they have been implemented, coupled with an attempt to account for their failure. Possible causes discussed include iatrogenic injury during hematoma evacuation, secondary injury initiated by hematoma persistence after evacuation, and inadequate therapeutic power arising from an excessively narrow focus on a single component of the complex pathophysiology of ICH injury. To conclude, we propose several strategies, such as enhancing endogenous hematoma resolution, hematoma evacuation-based neuroprotection, and multi-targeted therapy, that hold promise as prospects for the extension of anti-ICH therapy into the domain of clinical significance.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Christopher Stone
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Municipal Geriatric Medical Research Center, Beijing, China.
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Pedro KM, Chua AE, Lapitan MCM. Decompressive hemicraniectomy without clot evacuation in spontaneous intracranial hemorrhage: A systematic review. Clin Neurol Neurosurg 2020; 192:105730. [PMID: 32058207 DOI: 10.1016/j.clineuro.2020.105730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/03/2020] [Accepted: 02/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Decompressive hemicraniectomy (DH) effectively alleviates increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) and malignant middle cerebral artery (MCA) infarction. Its role in the management of spontaneous intracranial hemorrhage (SICH) however remains uncertain. This study aims to review the efficacy and safety of DH without clot evacuation in SICH. PATIENTS AND METHODS A systematic literature search of PubMEd, EMBASE, Scopus and Cochrane Library Central Register of Control Trials was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and end points. Primary endpoint was overall mortality. Secondary endpoint was functional outcome using modified Rankin scale (mRs) or Glasgow outcome scale (GOS). RESULTS Nine studies with a total of 146 patients who underwent DH without clot evacuation include: 1 RCT, 3 cohort, 2 case series, and 3 case-control studies. Age range was 40-60 years, with majority of patients presenting with a relatively depressed preoperative sensorium (GCS 6-8), large hematoma volumes (>50 mL), and deep locations (basal ganglia and thalamus). Pooled analysis showed a favorable outcome in 53 %, a mortality rate of 26 % and a complication rate of 35.8 %. CONCLUSION DH without clot evacuation may offer functional and mortality benefit in patients with spontaneous ICH, based on limited and heterogeneous studies.
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Affiliation(s)
- Karlo M Pedro
- Section of Neurosurgery, Department of Neurosciences, University of the Philippines-Manila, Philippine General Hospital.
| | - Annabell E Chua
- Section of Neurosurgery, Department of Neurosciences, University of the Philippines-Manila, Philippine General Hospital
| | - Marie Carmela M Lapitan
- Insitute of Clinical Epidemiology, National Institutes of Health, University of the Philippines-Manila, Philippines; Department of Surgery, University of the Philippines Manila-Philippine General Hospital, Manila, Philippines
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18
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Gildersleeve KL, Hirzallah MI, Esquenazi Y, Moomaw CJ, Sekar P, Cai C, Tandon N, Woo D, Gonzales NR. Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective, Propensity Score Matched Study. J Stroke Cerebrovasc Dis 2019; 28:104361. [PMID: 31515185 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104361] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/14/2019] [Accepted: 08/18/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. METHODS We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. RESULTS In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. CONCLUSIONS In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.
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Affiliation(s)
| | | | - Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Padmini Sekar
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Chunyan Cai
- Department of Internal Medicine, McGovern Medical School, Houston, Texas
| | - Nitin Tandon
- Vivian L. Smith Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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Poblete RA, Zheng L, Arenas M, Vazquez A, Yu D, Emanuel BA, Kim-Tenser MA, Sanossian N, Mack W. Older Age Is Not Associated with Worse Outcomes Following Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:104320. [PMID: 31395424 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Decompressive hemicraniectomy (DHC) is commonly offered after large spontaneous intracerebral hemorrhage (ICH) as a life-saving measure. Based on limited available evidence, surgery is sometimes avoided in the elderly. The association between age and outcomes following DHC in spontaneous ICH remains largely understudied. OBJECTIVE The goal of this study is to investigate the influence of older age on outcomes of patients who undergo DHC for spontaneous ICH. METHODS In this retrospective cohort study, inpatient data were obtained from the United States Nationwide Inpatient Sample from 2000 to 2011. Using International Classification of Diseases, ninth revision designations, patients with a primary diagnosis of nontraumatic ICH who underwent DHC were identified. The primary outcome of interest was the association of age to inpatient mortality and poor outcome. Subjects were grouped by age: 18-50, 51-60, 61-70, and more than 70 years. Sample characteristics were compared across age groups using χ2 testing, and univariate and multivariate Poisson Regression was performed using a generalized equation to estimate rate ratios for primary and secondary outcomes. RESULTS One thousand one hundred and forty four patient cases were isolated. Death occurred in an estimated 28.9% and poor outcome in 86.4%. In multivariate Poisson regression models, there was no difference in hospital mortality or poor outcome by age group. Although younger patients were more likely to be diagnosed with herniation, total complication rate was similar between age groups. CONCLUSIONS Our study results do not provide evidence that age independently predicts in-hospital mortality or poor outcomes. The true influence of age on outcomes is unclear, and further study is needed to determine which factors may be best in selecting candidates for DHC following spontaneous ICH.
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Affiliation(s)
- Roy A Poblete
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Ling Zheng
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Marcela Arenas
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alejandro Vazquez
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Derek Yu
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Benjamin A Emanuel
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - May A Kim-Tenser
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nerses Sanossian
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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20
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Abstract
Intracerebral hemorrhage (ICH) is a stroke subtype associated with significant morbidity and mortality. The purpose of this review is to provide an update on important research on ICH over the past three years. Topics covered include risk factors, imaging predictors of hematoma expansion, scoring schema to predict hematoma expansion, hemostatic therapies, acute blood pressure lowering, intraventricular administration of alteplase for intraventricular hemorrhage, and the current status of surgical therapies.
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Affiliation(s)
- Ravi Garg
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine , Maywood, IL, 60153, USA
| | - José Biller
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine , Maywood, IL, 60153, USA
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21
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Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage. Clin Neurol Neurosurg 2018; 174:1-6. [DOI: 10.1016/j.clineuro.2018.08.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/07/2018] [Accepted: 08/11/2018] [Indexed: 12/11/2022]
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22
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Sreekrishnan A, Dearborn JL, Greer DM, Shi FD, Hwang DY, Leasure AC, Zhou SE, Gilmore EJ, Matouk CC, Petersen NH, Sansing LH, Sheth KN. Intracerebral Hemorrhage Location and Functional Outcomes of Patients: A Systematic Literature Review and Meta-Analysis. Neurocrit Care 2017; 25:384-391. [PMID: 27160888 DOI: 10.1007/s12028-016-0276-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) has the highest mortality rate among all strokes. While ICH location, lobar versus non-lobar, has been established as a predictor of mortality, less is known regarding the relationship between more specific ICH locations and functional outcome. This review summarizes current work studying how ICH location affects outcome, with an emphasis on how studies designate regions of interest. METHODS A systematic search of the OVID database for relevant studies was conducted during August 2015. Studies containing an analysis of functional outcome by ICH location or laterality were included. As permitted, the effect size of individual studies was standardized within a meta-analysis. RESULTS Thirty-seven studies met the inclusion criteria, the majority of which followed outcome at 3 months. Most studies found better outcomes on the Modified Rankin Scale (mRS) or Glasgow Outcome Score (GOS) with lobar compared to deep ICHs. While most aggregated deep structures for analysis, some studies found poorer outcomes for thalamic ICH in particular. Over half of the studies did not have specific methodological considerations for location designations, including blinding or validation. CONCLUSIONS Multiple studies have examined motor-centric outcomes, with few studies examining quality of life (QoL) or cognition. Better functional outcomes have been suggested for lobar versus non-lobar ICH; few studies attempted finer topographic comparisons. This study highlights the need for improved reporting in ICH outcomes research, including a detailed description of hemorrhage location, reporting of the full range of functional outcome scales, and inclusion of cognitive and QoL outcomes.
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Affiliation(s)
- Anirudh Sreekrishnan
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Jennifer L Dearborn
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - David M Greer
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Fu-Dong Shi
- Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Audrey C Leasure
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Sonya E Zhou
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Charles C Matouk
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Nils H Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Lauren H Sansing
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, 06510, USA.
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23
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Abstract
Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
| | - Cappi Lay
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; Department of Neurocritical Care, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
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Goedemans T, Verbaan D, Coert BA, Kerklaan BJ, van den Berg R, Coutinho JM, van Middelaar T, Nederkoorn PJ, Vandertop WP, van den Munckhof P. Neurologic Outcome After Decompressive Craniectomy: Predictors of Outcome in Different Pathologic Conditions. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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25
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Lo YT, See AAQ, King NKK. Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Case-Control Study. World Neurosurg 2017; 103:815-820.e2. [DOI: 10.1016/j.wneu.2017.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/15/2022]
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26
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Mittal MK, LacKamp A. Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies. Front Neurol 2016; 7:210. [PMID: 27917153 PMCID: PMC5116572 DOI: 10.3389/fneur.2016.00210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/08/2016] [Indexed: 12/30/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.
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Affiliation(s)
- Manoj K Mittal
- Department of Neurology, University of Kansas Medical Center , Kansas City, KS , USA
| | - Aaron LacKamp
- Department of Anesthesiology, University of Kansas Medical Center , Kansas City, KS , USA
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27
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Complications following cranioplasty and relationship to timing: A systematic review and meta-analysis. J Clin Neurosci 2016; 33:39-51. [DOI: 10.1016/j.jocn.2016.04.017] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 11/21/2022]
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28
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Turner JD, Farmer JL, Dobson SW. Epidural Blood Patch Using Manometry for Sinking Skin Flap Syndrome. ACTA ACUST UNITED AC 2016; 6:355-7. [PMID: 27075425 DOI: 10.1213/xaa.0000000000000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe here a 55-year-old male patient with a medical history significant for chronic back pain and substance abuse with cocaine who sustained a traumatic subarachnoid hemorrhage after a fall from a roof while acutely intoxicated on cocaine requiring decompressive hemicraniectomy and cranioplasty that was complicated by an epidural abscess requiring a repeat craniectomy. He was diagnosed with sinking skin flap syndrome consistent with altered mental status and a sunken skin flap with increased midline shift. Despite treatment with Trendelenburg positioning and appropriate fluid management, the patient continued to decline, and an epidural blood patch was requested for treatment. After placement of the epidural blood patch using manometry in the epidural space, the patient's neurologic status improved allowing him to ultimately receive a cranioplasty. The patient is now able to perform several of his activities of daily living and communicate effectively.
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Affiliation(s)
- James D Turner
- From the Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Badenes R, Bilotta F. Neurocritical care for intracranial haemorrhage: a systematic review of recent studies. Br J Anaesth 2016; 115 Suppl 2:ii68-74. [PMID: 26658203 DOI: 10.1093/bja/aev379] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Intracerebral haemorrhage (ICH) is associated with significant early mortality (up to 50% at 30 days) and long-term morbidity (with permanent neurological deficits in 75-80% of patients) and represents a serious health issue worldwide. The past decade has seen a dramatic increase in clinical research on ICH diagnosis and treatment that has led to revision of the guidelines for the diagnosis and management of ICH from the American Heart Association and American Stroke Association in 2013. This systematic review reports recent clinical evidence (original studies published between September 2013 and July 2015) related to neurocritical care and intensive care unit management of patients with ICH. All but one publication included in this review report original studies related to managment of patients with intracerebral or subarachnoid haemorrhage. These include insights on risk stratification and neurocritical care or intensive care unit treatment, management of haemodynamic variables and mechanical ventilation (goal-directed fluid therapy, advanced haemodynamic monitoring, and avoidance of hyperoxia and hyperventilation), and pharmacological neuroprotection.
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Affiliation(s)
- R Badenes
- Department Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de València, València, Spain
| | - F Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy
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Abstract
OPINION STATEMENT Cerebral edema (i.e., "brain swelling") is a common complication following intracerebral hemorrhage (ICH) and is associated with worse clinical outcomes. Perihematomal edema (PHE) accumulates during the first 72 h after hemorrhage, and during this period, patients are at risk of clinical deterioration due to the resulting tissue shifts and brain herniation. First-line medical therapies for patients symptomatic of PHE include osmotic agents, such as mannitol in low- or high-dose bolus form, or boluses of hypertonic saline (HTS) at varied concentrations with or without subsequent continuous infusion. Decompressive craniectomy may be required for symptomatic edema refractory to osmotherapy. Other strategies that reduce PHE such as hypothermia and minimally invasive surgery have shown promise in pilot studies and are currently being evaluated in larger clinical trials. Ongoing basic, translational, and clinical research seek to better elucidate the pathophysiology of PHE to identify novel strategies to prevent edema formation as a next major advance in the treatment of ICH.
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