Sie sind auf Seite 1von 88

Literature Review on ICH

Brain Surgery School

M.D. Taylor MD.

56 yr. Old Male, known


HTN

56 yr. Old Male, known


HTN

Rationale for Surgical


Treatment

Because thats the way these cases


were managed on my last rotation
at ___________

Rationale for Surgical


Treatment

Dr. (insert COC here) is on call


tonight and that is the way he
manages this type of patient
COC= consultant of choice

What evidence is there in


the literature for / against
surgical treatment of HTN
related ICH?

McKissock, Richardson and


Taylor;
Lancet 1961; 2: 221-226
Before CT era
Clinical symptoms / LP / angiography
89 surgery: 91 conservative
treatment

McKissock, Richardson and


Taylor;
Lancet 1961; 2: 221-226
Mortality Surgery 65%
BMM 51%
Poor Outcome
BMM 66%

Surgery 80%

No significant difference between


treatment groups.

Juvela et al. J. Neurosurg 1989


The treatment of spontaneous intracerebral
hemorrhage

Inclusion: Unconscious
severe hemiparesis
dysphasia
admitted within 24 hours
onset
surgery within 48 hrs onset

Juvela et al. J. Neurosurg 1989


The treatment of spontaneous intracerebral
hemorrhage

One center
26 pts surgical
26 pts. BMM
Prospective
Randomized
No cerebellar, AVM, aneurysm

Juvela et al. J. Neurosurg 1989


The treatment of spontaneous intracerebral
hemorrhage

Mortality Overall 42%


BMM 38%
Surgery
46%
ADL Overall 20%
BMM 31%
Surgery
7%

Juvela et al. J. Neurosurg 1989


The treatment of spontaneous intracerebral
hemorrhage

Mortality rate of patients with GCS in


the range of 7-10 was significantly
lower in the surgical group (0/4) than
the BMM group (4/5) patients. p<0.05
BUT
All survivors from this subgroup had
very severe disabilities

Juvela et al. J. Neurosurg 1989


The treatment of spontaneous intracerebral
hemorrhage

It is concluded that spontaneous


supratentorial ICHs should be
treated conservatively

Scoreboard
Surgery

BMM

Auer et al. J. Neurosurg 1989


Endoscopic Surgery vs. Medical Treatment
for Spontaneous ICH: a Randomized Trial

Randomized
?Prospective
One center

50 surgical
50 BMM

Auer et al. J. Neurosurg 1989


Endoscopic Surgery vs. Medical Treatment
for Spontaneous ICH: a Randomized Trial

Inclusion criteria
No underlying structural etiology
age 30 to 80 years
hematoma >10 cubic cm
LOC or neuro deficit
Medically stable
Surgery within 48 hours of onset
Location: subcortical / putaminal/ thalamic

Auer et al. J. Neurosurg 1989


Endoscopic Surgery vs. Medical Treatment
for Spontaneous ICH: a Randomized Trial

Outcomes at 6 months
Mortality Surgery 30%
BMM 70%
(p<0.05)
Good outcome Surgery 40%
BMM 25%

Auer et al. J. Neurosurg 1989


Endoscopic Surgery vs. Medical Treatment
for Spontaneous ICH: a Randomized Trial

The outcome of surgical patients with


putaminal or thalamic hemorrhage was no
better than for those with medical
treatment
?A rationale for operating on subcortical
hematomas

Scoreboard
Surgery

BMM

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

Prospective
Randomized
One center

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

Inclusion criteria:
Putaminal ICH
ICH >3cm in diameter
30-75 years of age
History of HTN
Present within 24 hours of onset
LOC or neuro deficit

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

3 Arms
1) BMM and Microsurgery
2) BMM and ICP monitor (CSF
drainage)
3) BMM alone

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

3 Arms
1) BMM and Microsurgery 8 pts
2) BMM and ICP monitor
4 pts
3) BMM alone
9 pts

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

Study interrupted after 21 patients had


been studied. No differences were found
among groups for age, admission BP, time
interval to hospital arrival
NO subjects capable of returning to
prestroke activity

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

Outcomes at 6 months
Mortality Surgery 78%
BMM
67%
Poor outcome

Surgery 78%
BMM
83%

H.H. Batjer et al. Arch Neurol. 1990


Failure of Surgery to Improve Outcome in
Hypertensive Putaminal Hemorrhage. A
Prospective Randomized Trial

These results suggest that current


medical and neurosurgical therapies
remain ineffective in preventing the
devastating consequences of
hypertensive putaminal
hemorrhage

Scoreboard
Surgery

BMM

Chen et al. Acta Acad Med Shanghai


1992.
A prospective randomized trial of surgical
and conservative treatment of
hypertensive intracranial haemorrhage

Article in Chinese
Prospective
Randomized

Chen et al. Acta Acad Med Shanghai


1992.
A prospective randomized trial of surgical
and conservative treatment of
hypertensive intracranial haemorrhage
Inclusion criteria

No imminent herniation
History of HTN
64 surgical
63 conservative
Cohort included patients with cerebellar
hematomas

Chen et al. Acta Acad Med Shanghai


1992.
A prospective randomized trial of surgical
and conservative treatment of
hypertensive intracranial haemorrhage
Outcomes at 3 months
Mortality Surgery 23%
BMM 17%
Poor outcome Surgery 63%
BMM 50%
No difference between tx groups
(in spite of including cerebellar ICH)

Scoreboard
Surgery

BMM

L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)

Prospective
Randomized
Includes U of T alumnus P. Shedden
But run by a Neurologist (hence cute
name for the trial Stich)

L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)

Inclusion criteria:
>9ml clot
GCS 5-15
within 12 hours of ictus
Open craniotomy versus BMM

L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)

Outcome at 6 months
Mortality Surgery 24%
BMM 18%
Poor outcome
BMM 69%

Surgery 50%

L. B. Morgenstern et al.
Surgical treatment for intracerebral
hemorrhage (STICH)

Conclusions
Early surgery is feasible
Modest benefit for survival among
surgical cohort at one month but
not by six months

Scoreboard
Surgery

BMM

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Randomized
Prospective
Multi-centered

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Inclusion criteria
ICH volume >10 cm cubic
focal neurologic deficit
GCS>4
therapy within 24 hours of onset
Surgery within 3 hours random.
No aneurysm / AVM

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Enrolled
9 surgical patients
11 BMM patients
Intended to see whether early
treatment is feasible

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Results
median time to presentation:3 hrs 17 min
med rand to surgery: 1 hr 20 mins
Onset to surgery: 8 hours, 35 minutes
(it took 4 hours to randomize pts?)

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Outcomes:
Poor outcome

Mortality

Surgery 44%
BMM
64%
Surgery 22%
BMM
27%

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Outcomes 3 months
GOS: no sig. Difference
(primary outcome measure)
GOS, Barthel index, Rankin scale: no sig.
(secondary outcome measures)

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

BUT
significant difference in NIH stroke
scale
(4 vs. 14; P=0.04)
? Significance of this finding

Zuccarello et al. Stroke 1999


Early Surgical Treatment for Supratentorial
Intracerebral Hemorrhage: A Randomized
Feasibility Study

Very early surgical treatment for


acute ICH is difficult to achieve but
feasible at academic medical
centers and community hospitals.

Scoreboard
Surgery

BMM

0.5

Meta-analysis anyone?
If one is good, three must be better
1) Hankey GJ. Et al. Stroke 1997; 28:
2126-2132
2) Prasad K et al. Acta Neurol Scand
1997; 95: 103-110
3) Saver JL. Feldmann E. ed. Intracerebral
Hemorrhage 1994: 303-332

Meta-analyses
4 RCTS, 3 meta-analyses
Surgery no effect 2/3
Surgery may decrease mortality with
poor quality of life 1/3

Stroke: A Journal of Cerebral Circulation


1999 American Heart Association, Inc.
Volume 30(4) April 1999 pp 905-915
Guidelines for the Management of Spontaneous
Intracerebral Hemorrhage: A Statement for
Healthcare Professionals From a Special Writing
Group of the Stroke Council, American Heart
Association
[Aha Scientific Statement]
Broderick, Joseph P. MD; Adams, Harold P. MD;
Barsan, William MD; Feinberg, William MD;
Feldmann, Edward MD; Grotta, James MD; Kase,
Carlos MD; Krieger, Derek MD; Mayberg, Marc MD;
Tilley, Barbara PhD; Zabramski, Joseph M. MD;
Zuccarello, Mario MD

AHA Guidelines
# of RCT
Ischemic stroke
SAH
ICH

>315
78
4

AHA Guidelines
37,000 ICH in US in 1997
50% dead at one month
half of deaths in first two days
10% living independantly at 1 month
20% living independantly at 6 months

AHA Guidelines

Estimated 7000 operations a year in


the United States for removal of
ICH

AHA Guidelines

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

1. ICH is a medical emergency of the


highest degree with frequent early
neurological deterioration or death.
Vomiting, early change in level of
consciousness, and high elevation of
blood pressure in a patient with
acute stroke suggest ICH.

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

2. CT of the head is the imaging


procedure of choice in the initial
evaluation of suspected ICH (level
of evidence I, grade A
recommendation).

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

3. Angiography should be
considered for all patients without
a clear cause of hemorrhage who
are surgical candidates,
particularly young, normotensive
patients who are clinically stable
(level of evidence V, grade C
recommendation).

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

4. Angiography is not required for


older hypertensive patients who
have a hemorrhage in the basal
ganglia, thalamus, cerebellum, or
brain stem and in whom CT
findings do not suggest a
structural lesion. (level of evidence
V, grade C recommendation).

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

5. Timing of cerebral angiography


depends on the patient's clinical
state and the neurosurgeon's
judgment concerning the urgency
of surgery, if needed.

AHA Guidelines

Diagnosis of ICH: Summary and


Recommendations

6. MRI and MRA are helpful and may


obviate the need for contrast cerebral
angiography in selected patients. They
should also be considered to look for
cavernous malformations in
normotensive patients with lobar
hemorrhages and normal angiographic
results who are surgical candidates (level
of evidence V, grade C recommendation).

AHA Guidelines
Treatment of Acute ICH

No role for:
Steroids
Hemodilution
Glycerol
(as per negative RCTs)

AHA Guidelines
Treatment of Acute ICH

AHA Guidelines
Treatment of Acute ICH

AHA Guidelines
Treatment of Acute ICH

AHA Guidelines

Treatment of ICP secondary to Acute


ICH

Sometimes
Hyperosmolar solutions
Hyperventilation
Paralysis
Never
Corticosteroids

AHA Guidelines

Treatment of ICP secondary to Acute


ICH

ICP monitor for pt GCS <9


Ventricular drain in pts who have or
are at risk for hydrocephalus

AHA Guidelines
Role of Surgery for ICH

AHA Guidelines
Prevention of ICH
Grade A
Treat HTN
Careful anticoagulation
Careful thrombolysis
Grade C
Lots of fruits and veggies
avoid alcohol and sympathomimetics

56 yr. Old Male, known


HTN

Interesting Papers

How do you account for


clinical deterioration in the
patient with ICH?
?edema
?hydrocephalus
?rebleed / ongoing bleeding

Deterioration

Brott T. et al. Stroke 1997: 28(1); 1-5

Substantial early hemorrhage


growth in patients with intracranial
hemorrhage is common and is
associated with neurological
deterioration

Deterioration

Kazui S. et al. Stroke 1996: 27(10); 17831787

17% of hematomas expand


Extremely rare after 24 hours

Deterioration

Zazulia et al. Stroke 1999: 30(6); 11671173

Hematoma enlargement in first 2 days


2nd and 3rd weeks, edema
Edema with larger hematomas
Only 10/65 CT repeated for clinical
deterioration showed increased mass effect

Deterioration

Fujii Y. et al. Stroke 1998: 29(6); 1160-1166

Hematoma enlargement likely with:


admission shortly after onset
heavy drinkers
irregularly shaped hematoma
decreased LOC
low serum level of fibrinogen

Hydrocephalus

Diringer M et al. Stroke 1998: 29(7); 13521357

50% of pts with supratentorial ICH


Hospital mortality 51% with hydro and only
2% without hydro
With hydro only 21% of pts went home,
without 35% went home
No improvement with ventriculostomy

Hydrocephalus

Phan T. et al. Stroke 2000: 31(9); 21572162

Mortality Overall 29%


w hydro
76%
Hydro only predictive of mortality for
putaminal bleed, not thalamus etc.
Hydro and GCS<8
Survival=
11%
No hydro, GCS>8 Survival=
100%

Hydrocephalus

Shapiro. et al. J. Neurosurg 1994: 80; 805809

28/28 patients with hemorrhagic


dilatation of the 4th ventricle died
Some survivors if blood in the fourth
but no dilatation

A.G. Thrift et al. Stroke 1996: 27(11), 20202025


Risk Factors for Cerebral Hemorrhage in
the Era of Well Controlled Hypertension
HTN doubles the risk of ICH
Use of aspirin not assoc. with ICH
Reduced ICH with:
CV disease
Arthritis
High Cholesterol
Moderately overweight
Using hormone replacement
Drinking coffee

Blood Pressure Control and Recurrence of


Hypertensive Brain Hemorrhage
S. Arakawa et al. Stroke 1998: 29(9); 1806-1809

Diastolic BP sig higher in group with


recurrent ICH (f/u=2.8 years)
No effect of systolic BP
No patient with DBP <70 mm Hg had
a recurrent episode of ICH

Differing Temporal Patterns of Onset


in Subgroups of Patients with ICH
S. Passero et al. Stroke 2000: 31(7); 15381544

Risk of ICH greater on Monday


among population with jobs
Clustering of ICH in AM due to
increase in sympathetic tone and
BP on wakening

Prognostic Value and Determinants of First


Day Mean Arterial Pressure in Spontaneous
Supratentorial Intracerebral Hemorrhage
R. Fogelholm. Stroke 1997: 28(7); 13961400
Most important predictors of 28 day
survival:
Level of consciousness
First day MAP (bad if >145 mm Hg)

Rate of Stroke Recurrence in Patients with


Primary Intracerebral Hemorrhage
M. Hill et al. Stroke 2000: 31(1); 123-

Survivors
2.4% risk/year for recurrent ICH
3.0% risk/year for ischemic
stroke
Nice data set to look at as it consists
of 431 cases of ICH, all from TWH

Rate of Stroke Recurrence in Patients with


Primary Intracerebral Hemorrhage
M. Hill et al. Stroke 2000: 31(1); 123-

Rate of Stroke Recurrence in Patients with


Primary Intracerebral Hemorrhage
M. Hill et al. Stroke 2000: 31(1); 123-

Rate of Stroke Recurrence in Patients with


Primary Intracerebral Hemorrhage
M. Hill et al. Stroke 2000: 31(1); 123-

MRI Features of Intracerebral


Hemorrhage Within 2 Hours From
Symptom Onset

I. Linfante et al. Stroke 1999: 30(11); 22632267

These authors managed to get an


MRI within 23 minutes of symptom
onset in one patient.

Diagnostic Cerebral Angiography?: A


Prospective Study of 206 cases and
Review of the Literature
Zhu et al. Stroke 1997: 28(7); 14061409

Diagnostic cerebral angiography


should be considered for all
spontaneous ICH patients except
those over 45 years old with
preexisting HTN in thalamic,
putaminal, or post-fossa
hemorrhages.

Predicting neurologic deterioration in


patients with cerebellar hematomas
St. Louis EK. Et al. Neurology 1998: 51; 13641369

High risk for deterioration:


Hydrocephalus
Vermian hematoma

Apolipoprotein E Genotype and the Risk of


Recurrent Lobar Intracerebral Hemorrhage
ODonnell et al. New Eng J Med 2000: 342;
240-5

2 year follow-up
E3/E3 genotype 10% recurrence
E2 or E4 allele
recurrence

28%

Das könnte Ihnen auch gefallen