Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
January2011 Vol.48 Issue:      1 Table of Contents
Full Text
PDF


Early outcome of Conservative versus Surgical Treatment of Spontaneous Supratentorial Intracerebral Hemorrhage

Husam S. Mourad1, Ayman A. Enab2, Ahmed M. Abdelalim1

Departments of Neurology1, Neurosurgery 2, Cairo University; Egypt



ABSTRACT

Background: Spontaneous supratentorial intracerebral hemorrhage (ICH) is one of the most severe types of stroke. The decision about whether and when to surgically remove ICH remains controversial. Early surgery to limit the mechanical compression of brain and the toxic effects of blood may limit injury. Objective:  To investigate the early outcome and effectiveness of surgery as compared with conservative medical treatment in supratentorial intracerebral hemorrhage. Methods: Forty Patients with supratentorial spontaneous ICH was assigned to surgical or best medical treatment. Twenty patients underwent surgical evacuation while twenty were received conservative medical therapy. A history and examination, including an assessment by Glasgow Coma Scale (GCS) and of the neurological status by the National Institutes of Health Stroke Scale (NIHSS), were obtained at the time of admission and after one month. Glasgow outcome scale (GOS) was performed after one month. Results: There were no statistically significant differences in GOS, GCS or NIHSS after one month of treatment (p>0.05). There was 15% mortality each group with no statistically significant difference (p>0.05). Patients with baseline GCS ≥9 had a better final GCS (p=0.035) in the conservative compared to surgical groups but no significant difference in final NIHSS or GOS (p>0.05). Conclusion: we conclude that surgical evacuation of supratentorial intracerebral has a limited benefit compared to conservative medical treatment. It may be considered in large hematomas (>80cc) with moderate impairment of conscious level. Initial GCS is better than NIHSS in the prediction of outcome and mortality.  [Egypt J Neurol Psychiat Neurosurg.  2011; 48(1): 85-92]

 

Key Words: Spontaneous intracerebral hemorrhage- surgical treatment - conservative management – GCS – GOS- NIHSS.

 

Correspondence to Hosam S. Mourad, Department of neurology, Cairo University, Egypt.

Tel.: +20101554417. E-mail: husamsalah76@yahoo.com




INTRODUCTION

 

Spontaneous supratentorial intracerebral hemorrhage (ICH) is one of the most severe types of stroke (1). It is estimated that this condition affects 10-20 in 100 000 people every year with a mortality between 23-58% (2, 3). The pathophysiology of brain injury surrounding the hematoma is due to the mechanical effects of the growing mass of blood as well as the subsequent toxic effects of blood in the surrounding brain tissue. The decision about whether and when to surgically remove ICH remains controversial. Early surgery to limit the mechanical compression of brain and the toxic effects of blood may limit injury, but the surgical risks in a patient with ongoing bleeding may be greater. In addition, operative removal of hemorrhage by craniotomy in all but the most superficial hemorrhages involves cutting through uninjured brain(4).

Hematoma evacuation improves the neurological and general condition, but surgery may cause brain damage. Hematoma evacuation reduces morbidity, shortens hospitalization, promotes the return to activities of daily life and reduces medical costs(5).

One randomized trial (International Surgical Trial in Intracerebral Hemorrhage: STICH) found no favorable outcome with early surgery compared with conservative treatment(6).

This study was conducted to investigate the early outcome and effectiveness of surgery as compared with conservative medical treatment in spontaneous supratentorial intracerebral hemorrhage.

 

PATIENTS AND METHODS

 

Study design and population:

 

Forty patients with spontaneous ICH were assigned to surgical or best medical treatment. Twenty patients underwent surgical evacuation while twenty were planned for conservative medical therapy. Patients were recruited from Kasr El-Eini emergency department, Cairo University, Egypt.

Inclusion criteria were spontaneous ICH diagnosed by CT scan, ICH volume > 20cm3 with a focal neurological deficit, age>18years and presenting within less than 24 hours from onset of symptoms. Excluded were patients with infratentorial hemorrhage (e.g. cerebellar); multiple concomitant hemorrhages; concomitant subarachnoid hemorrhage or hydrocephalus; hemorrhagic transformation into a stroke; trauma related to onset; patients with arteriovenous malformations, aneurysms; hemorrhage secondary to bleeding tendency whether due to a medical condition (e.g. Hepatic failure) or drug induced (e.g. Anticoagulants).

 

Methods:

A)  Clinical evaluation of the conscious level by Glasgow Coma Scale (GCS)(7) and neurological status by the National Institutes of Health Stroke Scale (NIHSS)(8) were performed at the time of admission and one month after treatment. Proper history taking to exclude drug induced hemorrhage. Glasgow outcome scale (GOS) was performed one month after treatment (9). Patients with GOS of 1 or 2 were considered of good outcome and patients with GOS of 3, 4 or 5 were considered of poor outcome (10).

 

B)   Neuroradiological assessment: The Neuro-radiological assessment was performed in the emergency unit using a CT scanner (Toshiba Aquilion®). The diagnosis of spontaneous ICH was performed on acute onset of neurological symptoms and signs confirmed by CT scan. The site of hemorrhage was classified into temproparietal, parietal, occipitoparietal, temproparietooccipital and the lateralization of hemorrhage was illustrated in both groups of patients. The baseline volume of ICH was measured according to a bedside method of measuring CT ICH volume. The Broderick’s formula (AxBxC)/2 was used (11), where A is the greatest hemorrhage diameter by CT, B is the diameter 90 degrees to A and C is the approximate number of 10 mm CT slices with hemorrhage. Patients were classified according to hematoma size into moderately sized (30-79cc) and large hematomas (≥80cc) according to Pantazis et al.(12).

 

C)  Laboratory testing: Coagulation profile, complete blood picture, Liver and renal functions were performed to exclude medical causes of bleeding tendency.

 

Medical treatment

Medical therapy included osmotherapy, blood pressure control, fever control, seizure prophylaxis, deep venous thrombosis prophylaxis, intravenous fluids, H2 blockers, maintenance of normoglycemia, and early nutritional support. Intubation was performed in patients as needed for respiratory depression, airway protection.

 

Surgical treatment:

 

After the informed consent process, patients selected for surgical therapy were taken to the operating room as soon as possible not later than 24 hours of symptom onset. All surgical procedures were performed by the same neurosurgeon.

 

All surgical cases underwent decompressive craniotomy under general anesthesia, in supine position. Intravenous antibiotics were administered pre-, intra- and post-operatively. Intravenous phenytoin and corticosteroids, intra-operative osmotherspy (Mannitol and furosemide) was administered to decrease the intracranial pressure. Scalp preparation, sterilization and linear or horseshoe scalp incision were performed according to the localization of the hematoma. Hemostasis of the scalp bleeding by clips. Periosteal incision, burr holes and cutting the bone with Gigle saw were performed then elevation of the bone flap, hitching stitches for the dura, cruciate incision of the dura, coricotomy  incisions and using Leila spatula to open the space. Removal of the clots and hemostasis were microscopically assisted.

 

Closure was performed in anatomical layers by water tight dural stitches, fixation of the bone flap by stainless wire, closure of the subgalial layer and then scalp by proline stitches with suction drain.

 

 

Statistical Analysis:

 

SPSS computer program (version 11) was used for data analysis. Data were expressed as mean  standard deviation (SD) or percentage (%). Comparison between the numerical data of two groups was performed using unpaired t test. Pearson’s correlation coefficient was used to determine significant correlations between the different qualitative variables.  Spearman’s correlation was used for non-parametric correlation.  P value of 0.05 or less was considered significant.

 

RESULTS

 

 

The surgical group included thirteen male patients (65 %) and 7 female patients (35%). The conservative group included 11 male patients (55%) and 9 female patients (45%) with no significant difference in sex distribution among both groups (p>0.05) in (Table 1). There were no significant differences in age (p>0.05) or baseline hemorrhage size (p>0.05) among both groups. None of the patients in both groups had rebleeding.

 

 I. Comparative Results:

 

Comparing surgical treatment to the conservative treatment groups at baseline, there were no statistically significant differences as regards the hemorrhage size (p>0.05), baseline GCS (p>0.05), final GCS (p>0.05), baseline NIHSS (p>0.05, final NIHSS (p>0.05) and final GOS P>0.05) as illustrated in Table (2). There was 15% mortality in the surgical group (3 patients) and 15% (3 patients) mortality in the conservative group with no statistically significant difference (p>0.05). All mortalities in both groups had a baseline GCS of 5 or less. Comparing patients with baseline GCS ≥9 among both groups showed a better final GCS in the conservative group (p=0.035) but no significant difference in final NIHSS (p>0.05) or GOS (p>0.05).

There was no significant difference in outcome as measured by GOS among both groups (p>0.05) (Table 3)

Comparing patients within the conservative group with moderate (30-79cc) to large sized hematoma (>80cc) there was a statistically significant difference in baseline GCS (p=0.000), NIHSS (p=0.007), final GCS (0.01), final NIHSS (0.06) and final GOS (0.008).

Comparing patients within the surgical group with moderate (30-79cc) to large sized hematoma (>80cc) there was a statistically significant difference in baseline GCS (p=0.02), NIHSS (p=0.000). This difference was not significant 30 days after surgery with regards GCS (p=0.141), NIHSS (p=0.064) and GOS(p=0.084) where scores improved more significantly in patients with large sized hematomas compared to moderate sized hematomas 30 days following. None of the patients in the surgical group had re-bleeding following surgery. There were no significant differences in all parameters among patients with different sites of hemorrhage (p>0.05), side of hemorrhage (p>0.05) or among males and females (p>0.05).

 

II. Correlative Results:

 

In the group of patients on conservative medical treatment, there was a highly statistically significant negative correlation between size of hemorrhage and baseline GCS (r=-0.765, p=0.000) and GCS after 30 days (r=-0.896, p=0.000) and there was a statistically significant positive correlation between baseline hemorrhage size and baseline NIHSS (r=0.769, p=0.000), NIHSS after one month (r=0.998, p=0.000) and GOS (R=0.469, p=0.037). There was a highly statistically significant positive correlation between baseline GCS and GCS after one month (r=-0.805, p=0.000) and there was a highly statistically significant negative correlation between baseline GCS and baseline NIHSS (r=-0919, r=0.000), NIHSS after one month (r=0.998, p=0.000) and GOS (R=-501, p=0.024).

The surgical group showed significant negative correlation between hemorrhage size and baseline GCS (r=-517, p=0.02) but not with GCS after 30 days (r=-427, p=0.061) and a positive significant correlation between baseline hemorrhage size baseline NIHSS (r=0.698, p=0.001), NIHSS after 30 days (r=0.525, p=0.017) and GOS (R=0.473, p=0.035). Baseline GCS showed a significantly positive correlation with GCS after 30 days (r=0.477, p=0.034) and a significant negative correlation with baseline NIHSS (r=-0.907, p=0.000) and NIHSS after 30 days (r=-0.448, p=0.047) but not with GOS (R=-0.381, p=0.098).

There were no significant correlations between age and any of the parameters in all groups and subgroups of patients (p>0.05).

 

Figure (1) shows a CT scans of 2 surgical cases before and 30-days after evacuation of intracerebral hematomas.

 


Table 1. Distribution of patients with supratentorial intracerebral hemorrhage.

Group

Surgical group (n=20)

Conservative group (n=20)

Frequency

Percent

Frequency

Percent

Gender

Male

13

65

11

55

Female

 

7

35

9

45

Site of hemorrhage

Temporoparietal

15

75

10

50

Parietal

0

0

7

35

Occipitoparietal

3

15

0

0

Temproparietoccipital

 

2

10

3

15

Lateralization of hemorrhage

Right

13

65

18

90

Left

 

7

35

2

10

 

Table 2. Comparison between surgical and conservative treatment groups of patients with supratentorial intracerebral hemorrhage

 

Variables

Surgical group

Conservative group

 

P value

Mean

SD

Mean

SD

Age (years)

56.65

11.47

49.60

15.28

0.107

Hemorrhage size (cc)

80.65

24.38

67.75

21.49

0.084

GCS baseline

9.55

2.74

11.20

3.33

0.096

GCS final

11.1

5.71

12.45

5.39

0.447

NIHSS baseline

20.85

10.37

18.45

10.65

0.475

NIHSS final

17.20

15.07

13.30

12.44

0.378

GOS

2.05

1.669

1.75

1.446

0.547

GCS Glasgow coma scale, GOS Glasgow outcome scale, NIHSS National institute of health stroke scale, SD standard deviation

Table 3. Outcome of patients with supratentorial intracerebral hemorrhage.

Group

Surgical group (n=20)

Conservative group (n=20)

 

P value*

Frequency

Percent

Frequency

Percent

Good outcome (GOS=1-2)

 

14

70

16

80

 

0.358

Poor outcome (GOS= 3-5)

6

30

4

20

*Chi square test was used

GOS Glasgow outcome score

Figure 1. CT brain of a 58 years old patient showing pre- (Top left) & post- (Top right) evacuation of ICH & a 65 year old female showing pre- (Bottom left) & post- (Bottom right) evacuation of ICH included in the study.


DISCUSSION

 

There is incertitude about which is the proper treatment in a particular patient with spontaneous ICH(13). The variability among patients, as well as the great number of factors that influence their outcome, are important issues to take into account.

In our study of 40 patients with supratentorial ICH, we found no significant difference in the outcome among surgical and conservative group of patients. The STICH trial also showed no overall benefit of surgery over conservative treatment. Schwarz et al. (14) showed no benefit from surgery yet they emphasized on the benefit of surgical evacuation in progressively deteriorating patients to stop deterioration rather than improve outcome. On the contrary, Zuccarello et al. showed a better outcome in patients who underwent surgery than those on medical treatment(15). Cochrane systematic review (16) showed a benefit of surgery but no so robust as there were not enough clinical trials.

We found no significant difference in mortality rate among surgical and conservative groups was with 15% (3 patients) in each group all of which had a GCS of 3-5. Bilbao et al.(17) reported same result in a prospective study of 356 patients with supratentorial ICH. While Auer et al. reported mortality rate of 42% in the surgical group and 70% in the medical group(18). Chen et al. reported mortality in 23% of surgical patients and 17% in medical group (19). In other series mortality in the surgical group was 22% and 27% in medical group(15).

Our results showed that patients with GCS of 9 or more had a better final CGS but no significant difference in GOS in conservative treatment group. These results agreed with those of Morgenstern et al. (4) who recommended surgical intervention only if GCS is 8 or less. Predictors of poor outcome from ICH include admission GCS score(20), hematoma volume, age, presence of ventricular extension, and hydrocephalus (21). Qureshi et al. (22) suggested that early GCS score may not be helpful. In their series from Atlanta, 15 of 46 non-comatose patients deteriorated substantially during the initial 24 hours. ICH volume was a better early predictor of poor outcome than admission GCS score. This argues for rapid intervention before clinical deterioration based on a powerful early predictor such as hematoma volume (11).

In our study, the surgical evacuation was done within 24 hours from onset. There has been a variation in timing of surgery among different trials which showed better outcome in early intervention(4, 12, 15). Yet, early intervention within 4 hours or less from onset of hemorrhage was found to be associated with a higher rate of rebleeding(23).

In our study, we used decompressive craniotomy for evacuation of ICH. Marquardt et al. (24) used stereotaxy and endoscopic evacuation as an alternative for craniotomy and showed better results in terms of level of consciousness and GOS yet they only included non-comatose patients which may have also contributed to this outcome. So far, there are not enough randomized trials on minimally invasive operative procedures to decide its superiority over craniotomy. This issue remains a matter of controversy.

 

Conclusion:

 

We conclude that surgical evacuation of supratentorial ICH has a limited benefit on outcome compared to conservative medical treatment. It may be only considered in large hematomas (>80cc) with moderate impairment of conscious level. Initial GCS is better than NIHSS in the prediction of outcome and mortality. Thus the decision of whether or not to surgically evacuate supratentorial ICH should depend on a combination of hematoma size and initial GCS. This combination may be the best current predictor of benefit, outcome and mortality following surgical treatment.

 

 

[Disclosure: Authors report no conflicts of interest]

 

REFERENCES

 

1.      Pérez-Nuñez A, Lagares A, Pascual B, Rivas JJ, Alday R, González P, et al. [Surgical treatment for spontaneous intracerebral haemorrhage. Part I: supratentorial haematomas]. Neurocirugia (Astur). 2008 Feb;19(1):12-24.

2.      Badjatia N, Rosand J. Intracerebral hemorrhage. Neurologist. 2005 Nov;11(6):311-24.

3.      Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke. 2007 Jun;38(6):2001-23.

4.      Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly ES, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010 Sep;41(9):2108-29.

5.      Umebayashi D, Mandai A, Osaka Y, Nakahara Y, Tenjin H. Effects and complications of stereotactic aspiration for spontaneous intracerebral hemorrhage. Neurol Med Chir (Tokyo). 2010;50(7):538-44.

6.      Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005 2005 Jan 29-Feb 4;365(9457):387-97.

7.      Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul;2(7872):81-4.

8.      Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989 Jul;20(7):864-70.

9.      Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma. 1998 Aug;15(8):573-85.

10.    Choy DK, Wu PH, Tan D, Yeo TT, Chou N. Correlation of the long-term neurological outcomes with completeness of surgical evacuation in spontaneous supratentorial intracerebral haemorrhage: a retrospective study. Singapore Med J. 2010 Apr;51(4):320-5.

11.    Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993 Jul;24(7):987-93.

12.    Pantazis G, Tsitsopoulos P, Mihas C, Katsiva V, Stavrianos V, Zymaris S. Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: A prospective randomized study. Surg Neurol. 2006 Nov;66(5):492-501; discussion -2.

13.    Broderick JP, Adams HP, Barsan W, Feinberg W, Feldmann E, Grotta J, et al. 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. Stroke. 1999 Apr;30(4):905-15.

14.    Schwarz S, Jauss M, Krieger D, Dörfler A, Albert F, Hacke W. Haematoma evacuation does not improve outcome in spontaneous supratentorial intracerebral haemorrhage: a case-control study. Acta Neurochir (Wien). 1997;139(10):897-903; discussion -4.

15.    Zuccarello M, Brott T, Derex L, Kothari R, Sauerbeck L, Tew J, et al. Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke. 1999 Sep;30(9):1833-9.

16.    Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev. 2008(4):CD000200.

17.    Bilbao G, Garibi J, Pomposo I, Pijoan JI, Carrasco A, Catalán G, et al. A prospective study of a series of 356 patients with supratentorial spontaneous intracerebral haematomas treated in a Neurosurgical Department. Acta Neurochir (Wien). 2005 Aug;147(8):823-9.

18.    Auer LM, Deinsberger W, Niederkorn K, Gell G, Kleinert R, Schneider G, et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg. 1989 Apr;70(4):530-5.

19.    Chen X, Yang H, Czherig Z. A prospective randomised trial of surgical and conservative treatment of hypertensive intracranial haemorrhage. Acta Acad Med Shanghai. 1992;19:237-40.

20.    Mayer SA, Rincon F. Treatment of intracerebral haemorrhage. Lancet Neurol. 2005 Oct;4(10):662-72.

21.    Masè G, Zorzon M, Biasutti E, Tasca G, Vitrani B, Cazzato G. Immediate prognosis of primary intracerebral hemorrhage using an easy model for the prediction of survival. Acta Neurol Scand. 1995 Apr;91(4):306-9.

22.    Qureshi AI, Safdar K, Weil J, Barch C, Bliwise DL, Colohan AR, et al. Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage. Stroke. 1995 Oct;26(10):1764-7.

23.    Morgenstern LB, Demchuk AM, Kim DH, Frankowski RF, Grotta JC. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology. 2001 May;56(10):1294-9.

24.     Marquardt G, Wolff R, Sager A, Janzen RW, Seifert V. Subacute stereotactic aspiration of haematomas within the basal ganglia reduces occurrence of complications in the course of haemorrhagic stroke in non-comatose patients. Cerebrovasc Dis. 2003;15(4):252-7.


  

 

 

الملخص العربي

 

النتيجة المبكرة للعلاج التحفظى مقابل الجراحى لنزيف المخ الفوق الخيمى التلقائى

 

يعتبر النزيف المخى أحد أخطر انواع السكتات الدماغية. و يعتبر قرار العلاج الجراحى لتقليل أثر النزيف على المخ مثارا للخلاف. تهدف هذة الدراسة إلى بحث النتيجة المبكرة للتدخل الجراحى مقابل العلاج التحفظى فى مرضى النزيف المخ الفوق الخيمى التلقائى. و شملت الدراسة اربعون مريضا بالنزيف المخى الفوق الخيمى التلقائى خلال أربع و عشرون ساعة من اصابتهم بالنزيف تم تقسيمهم الى مجموعتين متساويتين. تم استثناء المرضى المصابين بصدمات بالرأس أو المشكوك باصإبتهم بتمددات دموية بالمخ أو سرعة النزف و تم تشخيص النزيف باستخدام الأشعة المقطعية. و تم تقييم المرضى باستخدام مقياس جلاسجو للغيبوبة و مقياس مخرج جلاسجو و مقياس المعهد القومى للصحة للسكتة الدماغية. و تشير نتائج الدراسة الى عدم وجود نتائج ذات دلالة إحصائية بين العلاج التحفظى و الجراحى. وجد فارق ذو دلالة إحصائية فى النتيجة النهائية فى المجموعة الجراحية  بين المرضى المصابين بالنزيف المخى ذو حجم 80سم مكعب أو أكثر مقارنه بالمرضى المصابين بالنزيف المخى ذو حجم أقل من 80 سم. بلغت نسبة الوفيات 15% فى كل مجموعة دن فارق ذو دلالة احصائية. و نستخلص من النتائج أن العلاج الجراحى للنزيف المخ الفوق الخيمى التلقائى ذو فائدة محدودة و لا يجب استخدامة بشكل عام و لكن بشكل فردى لكل مريض أخذين فى الإعتبار مستوى وعى المريض و حجم النزيف.



2008 � Copyright The Egyptian Journal of Neurology,
Psychiatry and Neurosurgery. All rights reserved.

Powered By DOT IT