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SURGICAL MANAGEMENT OF
HAEMORRHAGIC STROKE
Prof Nimrod Juniahs Mwang’ombe
MBChB (UoN), MMedSug, PhD (Lond)
Professor of Surgery University of Nairobi,
Kenyatta National Hospital, Kenya
Introduction
Spontaneous intracerebral haemorrhage (SICH)
is defined in this review as a blood clot that
arises in the brain parenchyma in the absence
trauma or surgery.
Causes
Primary:
70 to 80%
rupture of small vessels damaged by
hypertension or amyloid angiopathy
Secondary:
associated congenital and acquired
Conditions, vascular anomalies,
coagulopathies, tumors, and
various drug therapies.
Most frequent sites:
basal ganglia, thalamus,
subcortical white matter of the cerebral lobes,
cerebellum, and brainstem.
Incidence of SICH
• Stroke is the third leading cause of death in the US.
KENYA HIV/AIDS 29.3% , child birth-related conditions 9%,
respiratory infections including TB 14.4%, diarrheal diseases 6%,
malaria 5.8%, STROKE 3.3%, heart attacks 2.8%, road traffic
accidents 1.9%, and violence 1.6%.
Highest cause of morbidity in Kenya: Infectious diseases,
cardiovascular diseases, cancer
(http://www.who.int/countries/ken/en)
• Spontaneous ICH;10 to 15% of all strokes, higher mortality than
either ischemic stroke or SAH, with only 38% of affected persons
surviving 1 year.[31]
• African Americans and Japanese the incidence is2x that in
caucasians. (50-55/100000) [16,118] . >Men, > increasing age [16]
• Peak incidence in the morningincrease in sympathetic tone or
arterial blood pressure.
Risk Factors
• Hypertension continues to be the single
greatest modifiable risk factor for SICH
Clinical features:Initial Presentation
• The classic presentation; sudden onset of focal
neurological deficit, progressive S&S over hours,
altered consciousness, elevated BP.
• Supratentorial hemorrhage: contralateral sensory
or motor deficits, aphasia, gaze deviation, and
hemianopia.
• Infratentorial hemorrhages: signs of brainstem
dysfunction, lower cranial nerve abnormalities,
ataxia, nystagmus, and dysmetria.
• Elevation in blood pressure 90% of patients.
• Seizures 10% of patients.
Clinical features:Initial Presentation
• Blood may rupture into the ventricles and cause
hydrocephalus. Rarely, blood finds its way into
the subarachnoid space.
• A large hemorrhage can raise ICP to the level of
the blood pressure until bleeding is tamponaded.
Depending on clot location, this can result in
brain herniation, compression of the brainstem,
and death.
• Cerebellar clots greater than 3 cm in diameter
have a poor prognosis if left untreated.
Risk of Hematoma Enlargement
• In nearly 25% of initially alert patients presenting with
SICH, secondary deterioration in level of consciousness
occurs within the first 24 hours after onset due to
hematoma expansion and oedema formation.
• Early repeated CT scanning appears to increase the
rate of detection of hematoma enlargement.
Haematoma enlargement after 24 hours is reported to
be rare.
• Factors associated with enlargement include: heavy
alcohol consumption, liver disease, SBP greater than
200 mm Hg
Outcome After SICH
• Despite advances in neurocritical care and neurosurgery,
the prognosis for patients with SICH is poor.
• In one review of 37,000 patients SICH in 1997, 35 to 52%
were dead by 1 month postictus and only 20% were living
independently by 6 months. The volume of ICH, initial GCS
score, and intraventricular extension of the hemorrhage are
powerful predictors of 30-day mortality and morbidity
rates.
• Hematoma volume of 60 cm3 or > and GCS score 8 or <
associated with a 30-day mortality rate of 90%
• Haematoma volume of < 30 cm3 and GCS score 9 or >
associated with a 30 day mortality rate of only 19%
Diagnostic factors
Computerized tomography scanning
Initial diagnostic procedure of choice in acute stroke.
Demonstrate the size and location of the SICH as well as suggest other
potential causes such as tumor, vascular malformation, or aneurysm.
Related complications such as hydrocephalus, edema, herniation, and
intraventricular extension are easily identified as well as changes in the
CT scanning appearance of intracerebral hematomas over time.[28]
Laboratory evaluations
should include a complete blood count, liver function, coagulation
profile, electrolytes, toxicology screen. Underlying renal or liver
failure, acquired or iatrogenic coagulopathy, infection, or drug use
should be investigated.
Computerized tomography scanning
• Many modern CT scanners are able to calculate
hematoma volume directly by using special software.
• If direct volume measurements are not possible, a
rapid, simplified method of determining hematoma
volume has been described and validated.The formula
used—(A × B × C)/2—is an approximation for the
volume of an ellipsoid where A is the greatest
hemorrhage diameter on axial CT scans, B is the largest
diameter 90º to A, and C is the number of CT slices
with hemorrhage multiplied by the slice thickness.
Magnetic Resonance Imaging(MRI)
• MR and MR angiography are
becoming increasingly
useful in the diagnosis of
SICH.
Identifies brain tumors
and cavernous malformations
The MR imaging appearance of
SICH is complex and
depends on
hemoglobin breakdown products
over time.
Cerebral Angiography
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Despite advances in imaging technology, conventional cerebral angiography
remains the gold standard for diagnosis of vascular abnormality. A negative CT
angiogram, MR image, and MR angiogram cannot completely exclude a vascular
lesion and angiography is often needed for definitive diagnosis.
Although the risk of angiography is low, the diagnostic yield must be weighed
against the procedural risk at each institution.
The site of haemorrhage, patient age, pre-existing hypertension, and clinical status
must all be considered collectively before choosing angiography.
Elderly patients in whom the risk of surgery is unacceptable or neurological
disability is severe should not undergo angiography if identification of an
underlying vascular abnormality would have no effect on patient management.
Surgery in a young patient with SICH and evidence of herniation should not be
delayed by angiography.
A significant number of elderly hypertensive patients are found to harbor
potentially surgically treatable lesions such as aneurysms or AVM (49%).
Imaging features that suggest an underlying structural abnormality include SAH,
extracerebral hemorrhage, temporal lobe or perisylvian location, and
intraventricular extension
Pathophysiology mechanisms
• Intracerebral hemorrhage commonly occurs in the
basal ganglia, thalamus, cerebral lobes, brainstem, and
cerebellum.
• Primary tissue damage and distortion occur at the time
of hematoma formation when the blood spreads
between planes of white matter cleavage.
• Hemorrhage most commonly results from rupture of
the small penetrating arteries damaged by the
degenerative effects of chronic hypertension (Charcot
and Bouchard rupture of “microaneurysms’)
Medical Treatment
• Critical Care. Patients should be monitored in an intensive care unit
for a minimum of 24 hours.
• Seizure Prophylaxis. Seizures are more frequent in hemorrhagic
stroke than ischemic stroke.
• Blood Pressure Management. Mechanism; catecholamine release
and the Cushing response. Management of hypertension in SICH
remains controversial; no convincing evidence that lowering blood
pressure in the acute period after SICH alters the course or
prognosis
• To balance the two theoretical risks of hemorrhage extension
compared with worsening ischemia, the American Heart
Association recommended maintaining MABP below 130 mm Hg in
patients with preexisting hypertension and CPP above 70 mm Hg.
Management of Intracranial
Hypertension.
• Elevated ICP from SICH can result in herniation syndromes
and death.
• Monitoring and treatment of elevated ICP should reduce
secondary injury.
• Improved outcomes have not been linked with monitoring
and treatment of elevated ICP in SICH.
• Nevertheless, most authors recommend treatment when
ICP exceeds 20 mm Hg with a goal CPP greater than 60 to
70 mm Hg.
• ICP monitoring devices should be considered in all patients
who present with a GCS score less 9 or in those patients in
whom deteriorating clinical condition is believed to be due
to elevated ICP.
Management of Intracranial
Hypertension.
• Elevated ICP can have deleterious effects on CPP and, therefore,
global CBF
• Reduction in CPP leads to compensatory vasodilation, which
increases intracranial blood volume, in turn, increasing ICP and
further decreasing CPP.
• The physiological correction of this cycle is the systemic
hypertension response that increases CPP, leading to arteriolar
vasoconstriction, decreased intracranial blood volume, and lowered
ICP. Rosner and Becker used the term “ischemic response’ to
describe this phenomenon that Cushing proposed in 1902.
• The impact of ICP treatment and hematoma evacuation on CBF has
not been well studied, but some evidence exists that surgical
evacuation and elevated ICP treatment can improve CBF.
Management of Intracranial
Hypertension.
• Common strategies for managing elevated ICP:
elevation of the head of the bed, hyperventilation therapy, osmotic
therapy, sedation, and cerebrospinal fluid drainage.
Mannitol is often given when surgery is not considered appropriate.
Mechanical ventilation parameters should be adjusted to a PCO2
goal of 30 to 35 mm Hg.
Intraventricular blood is associated with a high mortality rate.
Ventriculostomy should be used in patients with hydrocephalus or
intraventricular hemorrhage (frequent clots in the catheter and
infections often diminish the beneficial effect on hydrocephalus and
neurological status).
Sedation and analgesics, or propofol can help control elevated ICP.
Barbiturate coma or hemicraniectomy may be necessary if all other
measures fail.
The role of surgery in the
management of spontaneous ICH
• Most neurosurgeons believe evacuation of
certain intracerebral hematomas can reduce
the mortality rate and improve outcomes
(almost 7000 operations are performed
annually in the US for SICH)
• The efficacy of surgery for SICH, however,
remains unproven.
Surgical Treatment
• Patients with relatively normal consciousness (GCS Scores 13–15)
rarely require surgery, whereas deeply comatose patients (GCS
Scores 3–5) rarely benefit from surgery.
• Surgery is therefore usually considered to have the most potential
benefit for the group of patients with GCS scores between 6 and 12
or in patients with deteriorating status.
• The optimal surgical technique for hematoma evacuation is not
agreed upon, although craniotomy remains the most common.[35]
• Traditional stereotaxy or frameless navigational systems, as well as
intraoperative ultrasonographic guidance, allow more precise clot
localization and minimization of injury to normal brain.
• Compared with craniotomy, minimally invasive techniques such as
stereotactic or endoscopic clot evacuation may offer the potential
for a reduced incidence of surgery-related complications and
improved efficacy.
Acute surgery for ICH caused by rupture of an
intracranial arterial aneurysm (Heiskanen)
Algorithm for cerebellar ICH
Randomized Trials of Surgical and Medical
Management: most recent trials
• There were 9 trials evaluating this condition
before STICH.
Early surgery vs initial conservative
treatment (STICH Trial)
Early surgery versus initial
conservative treatment in SICH
Patient selection
• 1033 patients from 107 centers in 27 countries across
the world were recruited in the trial over an eight year
period. Most participants were from European
countries, India 85 pts, China and Japan 20.
• Patients were eligible if they had a spontaneous
supratentorial intracerebral hemorrhage that had
arisen within 72 hours and the treating neurosurgeon
was not sure of the benefits of either treatment.
Patients were excluded if their bleed was secondary to
an aneurysm or AVM, or if they had brainstem
extension
What was the intervention?
Telephone randomization service was used. Within
24 hours of randomization, people randomized to surgical
arm underwent hematoma evacuation by the method of
choice of the responsible neurosurgeon. Those
randomized to medical arm, received the best available
medical care, and if at a later point it was deemed
important to evacuate the hematoma, they also
underwent surgery.
What was the outcome?
• Outcome assessment at six months was blinded.
The surviving patients or their care givers were
sent structured questionnaires which had
questions regarding the Glasgow outcome scale,
the Barthel Index and Modified Rankin Scale.
All analysis was done on an intention to treat
basis.
• The outcome assessment was dichotomized
based on median prognostic score at
randomization into good and poor prognoses.
Results
• 503 patients were randomized to early surgery and 530
to initial conservative treatment. The groups were well
matched in terms of age, gender, pre ICH functional
status, medical comorbids, site and volume of
hematoma and its depth from the surface.
In the surgical arm 26 patients and in the medical arm
25 patients lost to follow up. A further 9 in the surgical
arm and 8 in the medical arm were excluded from all
but the survival analysis as they did not fill out the
outcome assessment forms at six months.
Results
• The mortality rate at 6 months for the early
surgery group was 36% compared with 37%
for the initial conservative treatment group
(odds ratio 0·95 [0·73-1·23], p=0·707); Survival
during the first 6 months did not significantly
differ between the two groups (log-rank test,
p=0·678)
Results
• With the prognosis based dichotomy of the
extended Glasgow outcome scale, the
modified Rankin scale and the Barthel index,
there were no significant differences between
the surgical and initial conservative arms
(p=0.414, p=0.116 and p=0.144 respectively)
at six months.
Subgroup analysis
• Subgroup analysis had similar non significant
findings.
• The only subgroup to show heterogeneity of
treatment response was depth of hematoma
from cortical surface. A favorable outcome from
early surgery was more likely if the hematoma
was 1 cm or less from the cortical surface
(absolute benefit 8%; 0-15); interaction between
depth from cortical surface and treatment was
significant (p=0·02).
What were the conclusions?
• The authors conclude that the outcomes in
patients with spontaneous supratentorial
intracerebral hemorrhage do not differ
significantly whether they undergo early
surgery or initial conservative treatment. The
only subgroup to show favorable outcome with
surgery were patients with hematomas 1 cm or
less from the cortical surface. Therefore the role
of surgery continues to be uncertain except in a
small minority of patients.
What does stitch teach us?
• This is a landmark trial as randomized trials in
surgical patients with severe neurological
dysfunction are difficult. Additionally, patients
were "real world", interventions were not
"technically demanding". The trial is also quite
generalizable as it had patients from 27
countries across five continents.
What does stitch teach us?
• In developing countries in Africa the burden
on the health system is enormous.
• It is therefore important to know that
costly surgical intervention has no benefit on
mortality and functional outcome in patients
with spontaneous hypertensive intracerebral
hemorrhage
Conclusions from STICH
Approach to ICH after STICH
• Aneurysmal ICH: remove ICH & treat
aneurysm (Heisjkanen 1988)
• Cerebellar intracerebral haemorrhage:
Mathew algorithm (1995)
• Supratentorial ICH: early surgery if lobar and
GCS 9-13 (STICH I)
References
• Mendelow AD, Gregson BA, Fernandes (2013)
• Mathew and Teasdale (1995)
• Heikanen (1988)
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