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Surgery for Spontaneous Intracerebral Hemorrhage: Current Concept
Spontaneous intracerebral hemorrhage (ICH) into the brain parenchyma and into the ventricles presents as a severe stroke with high mortality, with uncontrolled hypertension, cerebral amyloid angiopathy, and more recently the anticoagulant-induced cerebral bleeds representing the main risk factors.  Unfortunately, interventions to stop hematoma expansion by rapid reduction of blood pressure, the use of recombinant activated factor eight, or the administration of tranexamic acid have not shown improvement in functional outcome. 
The theoretical advantages of evacuating the hematoma and preventing the acute effects of the blood products on the surrounding healthy brain tissue are counterbalanced by the risks of reaching out to the location of the bleeds in the deep basal ganglia structures and the thalamus through healthy cerebral tissue and the additional burden of postsurgical complications.
There is the need for emergency lifesaving surgical evacuation of large lobar hemorrhages and hematomas in the posterior fossa to avoid cerebral or brainstem herniation, and in such situations comparison of best medical management with surgical interventions does not lend itself to a randomized clinical trial (RCT) opportunity for an evidence-based assessment.
In about two-thirds of patients, acute hemorrhage into the brain parenchyma results in stoppage of bleeding through disruption and mass effect within the cerebral tissue. In the remaining one-third, hematoma expansion results in midline shift and an adverse outcome. The best medical management and neuro intensive care with interventions of recombinant activated factor eight reduced hematoma growth but did not decrease mortality or improve functional outcome. The use of tranexamic acid reduced hematoma expansion but did not improve the functional outcome at 90 days. Two large trials of blood pressure lowering—INTERACT-2 and ATACH-II—demonstrated that maintaining a systolic blood pressure around 120 to 130 mm Hg in the first 24 hours might result in improved functional outcome.
Hematoma volume greater than 30 mL had statistically unfavorable outcome and a volume greater than 60 mL with Glasgow Coma Scale (GCS) score lower than 8 had greater than 90% predicted 30-day mortality. A volume greater than 150 mL through abrupt increase in intracranial pressure (ICP) and critical reduction of cerebral perfusion pressure (CPP) leads to death.  Much smaller hematoma volumes in the posterior fossa due to obvious limitations of space to expand leads to brainstem herniation/compression with hydrocephalus and clinical deterioration when hematoma evacuation is of lifesaving consequence. 
Additional adverse effects of the blood products from the hematoma and secondary inflammation and edema resulting from the same would compound the mass effect, midline shift and decreasing cerebral perfusion consequent to rising ICP. 
26 March 2021 (online)
© 2021. Neurological Surgeons Society of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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- 1 van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9 (02) 167-176
- 2 Ariesen MJ, Claus SP, Rinkel GJE, Algra A. Risk factors for intracerebral hemorrhage in the general population: a systematic review. Stroke 2003; 34 (08) 2060-2065
- 3 Yamada M. Cerebral amyloid angiopathy: emerging concepts. J Stroke 2015; 17 (01) 17-30
- 4 Kuramatsu JB, Sembill JA, Huttner HB. Reversal of oral anticoagulation in patients with acute intracerebral hemorrhage. Crit Care 2019; 23 (01) 206
- 5 Frontera JA, Lewin JJ II, Rabinstein AA. et al. Guideline for reversal of antithrombotics in intracranial hemorrhage. Neurocrit Care 2016; 24 (01) 6-46
- 6 Qureshi AI, Palesch YY, Barsan WG. et al; ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016; 375 (11) 1033-1043
- 7 Sprigg N, Flaherty K, Appleton JP. et al; TICH-2 Investigators. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet 2018; 391 (10135) 2107-2115
- 8 Mayer SA, Brun NC, Begtrup K. et al; FAST Trial Investigators. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2008; 358 (20) 2127-2137
- 9 Wong JM, Ziewacz JE, Ho AL. et al. Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery. Neurosurg Focus 2012; 33 (05) E15
- 10 Xi G, Keep RF, Hoff JT. Mechanisms of brain injury after intracerebral haemorrhage. Lancet Neurol 2006; 5 (01) 53-63
- 11 Anderson CS, Heeley E, Huang Y. et al; INTERACT2 Investigators. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368 (25) 2355-2365
- 12 Moullaali TJ, Wang X, Martin RH. et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol 2019; 18 (09) 857-864
- 13 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; 24 (07) 987-993
- 14 Hemphill III JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC, Tuhrim S. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32 (04) 891-897
- 15 Witsch J, Neugebauer H, Zweckberger K, Jüttler E. Primary cerebellar haemorrhage: complications, treatment and outcome. Clin Neurol Neurosurg 2013; 115 (07) 863-869
- 16 de Oliveira Manoel AL, Goffi A, Zampieri FG. et al. The critical care management of spontaneous intracranial hemorrhage: a contemporary review. Crit Care 2016; 20: 272 DOI: 10.1186/s13054-016-1432-0.
- 17 Gong C, Boulis N, Qian J, Turner DE, Hoff JT, Keep RF. Intracerebral hemorrhage-induced neuronal death. Neurosurgery 2001; 48 (04) 875-882 discussion 882–883
- 18 Qureshi AI, Ling GS, Khan J. et al. Quantitative analysis of injured, necrotic, and apoptotic cells in a new experimental model of intracerebral hemorrhage. Crit Care Med 2001; 29 (01) 152-157
- 19 Hallevi H, Albright KC, Aronowski J. et al. Intraventricular hemorrhage: anatomic relationships and clinical implications. Neurology 2008; 70 (11) 848-852
- 20 Claude Hemphill III J, Lam A. Emergency neurological life support: intracerebral hemorrhage. Neurocrit Care 2017; 27 (01) 89-101
- 21 Hanley DF, Lane K, McBee N. et al; CLEAR III Investigators. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389 (10069) 603-611
- 22 Hinson HE, Melnychuk E, Muschelli J, Hanley DF, Awad IA, Ziai WC. Drainage efficiency with dual versus single catheters in severe intraventricular hemorrhage. Neurocrit Care 2012; 16 (03) 399-405
- 23 Staykov D, Kuramatsu JB, Bardutzky J. et al. Efficacy and safety of combined intraventricular fibrinolysis with lumbar drainage for prevention of permanent shunt dependency after intracerebral hemorrhage with severe ventricular involvement: a randomized trial and individual patient data meta-analysis. Ann Neurol 2017; 81 (01) 93-103
- 24 Li Y, Zhang H, Wang X. et al. Neuroendoscopic surgery versus external ventricular drainage alone or with intraventricular fibrinolysis for intraventricular hemorrhage secondary to spontaneous supratentorial hemorrhage: a systematic review and meta-analysis. PLoS One 2013; 8 (11) e80599 DOI: 10.1371/journal.pone.0080599.
- 25 Mckissock W, Richardson A, Taylor J. Primary intracerebral haemorrhage. Lancet 1961; 278: 221-226
- 26 Mendelow AD, Gregson BA, Fernandes HM. et al; STICH investigators. 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; 365 (9457) 387-397
- 27 Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM. STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; 382 (9890) 397-408
- 28 Auer LM, Deinsberger W, Niederkorn K. et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J Neurosurg 1989; 70 (04) 530-535
- 29 Vespa P, Hanley D, Betz J. et al; ICES Investigators. ICES (intraoperative stereotactic computed tomography-guided endoscopic surgery) for brain hemorrhage: a multicenter randomized controlled trial. Stroke 2016; 47 (11) 2749-2755
- 30 Hanley DF, Thompson RE, Muschelli J. et al; MISTIE Investigators. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 2016; 15 (12) 1228-1237
- 31 Hanley DF, Thompson RE, Rosenblum M. et al; MISTIE III Investigators. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019; 393 (10175) 1021-1032
- 32 Awad IA, Polster SP, Carrión-Penagos J. et al; MISTIE III Trial Investigators. Surgical performance determines functional outcome benefit in the minimally invasive surgery plus recombinant tissue plasminogen activator for Intracerebral hemorrhage evacuation (MISTIE) procedure. Neurosurgery 2019; 84 (06) 1157-1168
- 33 Mould WA, Carhuapoma JR, Muschelli J. et al; MISTIE Investigators. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 2013; 44 (03) 627-634
- 34 Kellner CP, Chartrain AG, Nistal DA. et al. The Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration (SCUBA) technique for minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2018; 10 (08) 771-776
- 35 Scaggiante J, Zhang X, Mocco J, Kellner CP. Minimally invasive surgery for Intracerebral hemorrhage. Stroke 2018; 49 (11) 2612-2620
- 36 Fung C, Murek M, Z’Graggen WJ. et al. Decompressive hemicraniectomy in patients with supratentorial intracerebral hemorrhage. Stroke 2012; 43 (12) 3207-3211
- 37 Hayes SB, Benveniste RJ, Morcos JJ, Aziz-Sultan MA, Elhammady MS. Retrospective comparison of craniotomy and decompressive craniectomy for surgical evacuation of nontraumatic, supratentorial intracerebral hemorrhage. Neurosurg Focus 2013; 34 (05) E3
- 38 Kirollos RW, Tyagi AK, Ross SA, van Hille PT, Marks PV. Management of spontaneous cerebellar hematomas: a prospective treatment protocol. Neurosurgery 2001; 49 (06) 1378-1386 discussion 1386–1387
- 39 Mathew P, Teasdale G, Bannan A, Oluoch-Olunya D. Neurosurgical management of cerebellar haematoma and infarct. J Neurol Neurosurg Psychiatry 1995; 59 (03) 287-292
- 40 Kobayashi S, Sato A, Kageyama Y, Nakamura H, Watanabe Y, Yamaura A. Treatment of hypertensive cerebellar hemorrhage–surgical or conservative management?. Neurosurgery 1994; 34 (02) 246-250 discussion 250–251
- 41 Kuramatsu JB, Biffi A, Gerner ST. et al. Association of Surgical Hematoma Evacuation vs conservative treatment with functional outcome in patients with cerebellar Intracerebral hemorrhage. JAMA 2019; 322 (14) 1392-1403
- 42 Hemphill JC II, Greenberg SM, Anderson CS. et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2015; 46 (07) 2032-2060
- 43 Steiner T, Al-Shahi Salman R, Beer R. et al; European Stroke Organisation. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9 (07) 840-855
- 44 Rabinstein AA, Wijdicks EFM. Surgery for intracerebral hematoma: the search for the elusive right candidate. Rev Neurol Dis 2006; 3 (04) 163-172
- 45 Kirkman MA, Greenwood N, Singh N, Tyrrell PJ, King AT, Patel HC. Difficulties with recruiting into neurosurgical clinical trials: the Surgical Trial in IntraCerebral Haemorrhage II as an example. Br J Neurosurg 2011; 25 (02) 231-234