====== Intracerebral hemorrhage surgery indications ======

Hematoma evacuation has been extensively studied because of the good results obtained by the procedure
((Freeman WD, Aguilar MI. Intracranial hemorrhage: diagnosis and management. Neurol
Clin. 2012;30(1):211-40, ix.
22.Gomes JA, Manno E. New developments in the treatment of intracerebral hemorrhage.
Neurol Clin. 2013;31(3):721-35.))
; nevertheless, the results of the Surgical Trial in Intracerebral Hemorrhage ([[STICH]]) and some randomized controlled trials suggest that surgery does not appear to offer any great advantage over conservative medical management in these patients
((Mendelow AD, Gregson BA. Early surgery versus initial conservative treatment in
patients withspontaneous supratentorial intracerebral haematomas in the International Surgical
Trial in Intracerebral Haemorrhage (STICH): a randomised trial.
Lancet2005;365(9457):387–97.))
((Fernandes HM, Gregson B. Surgery in intracerebralhemorrhage: the uncertainty
continues. Stroke 2000;31(10):2511–6.))
((Mitchell P, Gregson BA. Surgical options inICH including decompressive craniectomy. J
Neurol Sci 2007;261(1/2):89–98.)).
Other randomized studies and several meta-analyses
((Batjer HH, Reisch JS. Failure of surgery to improve outcome in hypertensive putaminal
hemorrhage: a prospective randomized trial. Arch Neurol 1990;47(10):1103–6.))
((Auer LM, Deinsberger W. Endoscopic surgery versus medical treatment for spontaneous
intracerebral hematoma: a randomized study. J Neurosurg 1989;70(4):530–5.))
((Juvela S, Heiskanen O. The treatment of [[spontaneous intracerebral hemorrhage]]: a
prospective randomized trial of surgical and conservative treatment. J Neurosurg
1989;70(5):755–8.))
((Morgenstern LB, Frankowski RF. Surgical treatment for intracerebral hemorrhage
(STICH): a single-center, randomized clinical trial. Neurology 1998;51(5):1359–63.))
((Teernstra OP, Evers SM. Meta analyses in treatment of spontaneous supra tentorial
intracerebral haematoma. Acta Neurochir (Wien)2006;148(5):521–8, discussion 528.))
((Zuccarello M, Brott T. Early surgical treatment for supra tentorial intracerebral
hemorrhage: a randomized feasibility study. Stroke 1999;30(9):1833–9.))
, have not yet been able to clearly elucidate the role of surgical management for this condition. Most recently, the STICH II trial data suggests that early surgery may have a small but clinically relevant survival advantage for patients with superficial hemorrhages without intra-ventricular hemorrhage (IVH) ((Mendelow AD, Gregson BA. Early surgery versus initial conservative treatment in
patients with spontaneous supra tentorial lobar intracerebral haematomas (STICH II): a
randomized trial. Lancet 2013;382(9890):397–408)).

Decompressive hemicraniectomy without hematoma evacuation has not received as much attention
((Rasras S, Safari H, Zeinali M, Jahangiri M. Decompressive hemicraniectomy
without clot evacuation in supratentorial deep-seated intracerebral hemorrhage.
Clin Neurol Neurosurg. 2018 Nov;174:1-6. doi: 10.1016/j.clineuro.2018.08.017.
Epub 2018 Aug 23. PubMed PMID: 30172088.
))

[[Intracerebral hemorrhage surgery]] is controversial; some patients may benefit, but indications for surgical treatment have not been conclusively defined
((Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M,
Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D;
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
Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069. Epub 2015 May 28. PubMed
PMID: 26022637.
)).

In patients with CT-proven primary supratentorial intracerebral haemorrhage, surgery added to medical management reduces the odds of being dead or dependent compared with medical management alone, but the result were not very robust. Hence, further randomised trials to identify which patients benefit from surgery and to evaluate less invasive methods are indicated
((Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial
intracerebral haemorrhage. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD000200.
doi: 10.1002/14651858.CD000200.pub2. Review. PubMed PMID: 18843607.
)).

Reserve surgical therapy for patients with life-threatening [[mass effect]] from supratentorial [[ICH]], individualizing treatment decisions based on assessments of prognosis with and without surgical therapy. Limited data suggest that supratentorial hematoma evacuation might reduce mortality for patients who are comatose, have a large hematoma with significant midline shift, or have elevated intracranial pressure (ICP) refractory to medical management
((Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M,
Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D;
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
Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069. Epub 2015 May 28. PubMed
PMID: 26022637.
)).

Because of the questionable efficacy of surgery, it should only be considered as a life saving procedure to treat refractory increases in ICP; even in these instances, decisions should be addressed on a per patient basis:

●Surgery should not be considered for patients who are either fully alert or deeply comatose. Patients with intermediate levels of arousal (obtundation-stupor) are more appropriate candidates.

●Features that support performing surgery include a recent onset of hemorrhage, ongoing clinical deterioration, involvement of the nondominant hemisphere, and location of the hematoma near the cortical surface.

●Features in favor of less aggressive therapy include serious concomitant medical problems, advanced age, stable clinical condition, remote onset of hemorrhage, involvement of the dominant hemisphere, and inaccessibility of the hemorrhage

----


see [[STICH]] Trial.

Surgical [[hematoma]] [[evacuation]] for supratentorial [[ICH]] is controversial; some patients may benefit, but [[indication]]s for surgical treatment have not been conclusively defined 
((Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M,
Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M; American Heart Association;
American Stroke Association Stroke Council; High Blood Pressure Research Council;
Quality of Care and Outcomes in Research Interdisciplinary Working Group.
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. Epub 2007 May 3. PubMed PMID: 17478736.
))
((Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly 
ES Jr, Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M,
Tamargo RJ; American Heart Association Stroke Council and Council on
Cardiovascular Nursing. 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. doi: 10.1161/STR.0b013e3181ec611b. Epub 2010 Jul 22. PubMed
PMID: 20651276; PubMed Central PMCID: PMC4462131.
))
((Hankey GJ, Hon C. Surgery for primary intracerebral hemorrhage: is it safe and effective? A systematic review of case series and randomized trials. Stroke 1997; 28:2126.))
((Batjer HH, Reisch JS, Allen BC, et al. Failure of surgery to improve outcome in hypertensive putaminal hemorrhage. A prospective randomized trial. Arch Neurol 1990; 47:1103.))
((Morgenstern LB, Demchuk AM, Kim DH, et al. Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage. Neurology 2001; 56:1294.))
((Minematsu K. Evacuation of intracerebral hematoma is likely to be beneficial. Stroke 2003; 34:1567.))
((Hankey GJ. Evacuation of intracerebral hematoma is likely to be beneficial--against. Stroke 2003; 34:1568.))
((Donnan GA, Davis SM. Surgery for intracerebral hemorrhage: an evidence-poor zone. Stroke 2003; 34:1569.))
((Mendelow AD, Gregson BA, Fernandes HM, 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; 365:387.))
((Nakano T, Ohkuma H. Surgery versus conservative treatment for intracerebral haemorrhage--is there an end to the long controversy? Lancet 2005; 365:361.))
((Gregson BA, Broderick JP, Auer LM, et al. Individual patient data subgroup meta-analysis of surgery for spontaneous supratentorial intracerebral hemorrhage. Stroke 2012; 43:1496.))

The guidelines of 2010 suggested consideration of standard craniotomy only for those who have lobar clots >30 mL (see [[ABC/2]]) within 1 cm of the surface
((Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M,
Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M; American Heart Association;
American Stroke Association Stroke Council; High Blood Pressure Research Council;
Quality of Care and Outcomes in Research Interdisciplinary Working Group.
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. Epub 2007 May 3. PubMed PMID: 17478736.
))
((Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly 
ES Jr, Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M,
Tamargo RJ; American Heart Association Stroke Council and Council on
Cardiovascular Nursing. 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. doi: 10.1161/STR.0b013e3181ec611b. Epub 2010 Jul 22. PubMed
PMID: 20651276; PubMed Central PMCID: PMC4462131.
)).

No other patient group is recommended for surgery, and no surgical method other than standard craniotomy is supported. The routine evacuation of supratentorial ICH in the first 96 hours is not recommended.

Open craniotomy is the most widely studied surgical techniques in patients with supratentorial ICH
((Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, Mayberg M,
Morgenstern L, Ogilvy CS, Vespa P, Zuccarello M; American Heart Association;
American Stroke Association Stroke Council; High Blood Pressure Research Council;
Quality of Care and Outcomes in Research Interdisciplinary Working Group.
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. Epub 2007 May 3. PubMed PMID: 17478736.
)).

Other methods include endoscopic hemorrhage aspiration, use of fibrinolytic therapy to dissolve the clot followed by aspiration, and CT-guided stereotactic aspiration. Studies of these less invasive techniques are in progress
((Gautschi OP, Schaller K. Surgery or conservative therapy for cerebral haemorrhage? Lancet 2013; 382:377.)).



Further studies are required to conclusively determine which patients should receive surgical therapy.


----

There is at present no clear indication for surgical removal of intracerebral haemorrhage (ICH) in the majority of patients. With deterioration from an initially good level of consciousness, many surgeons would agree that removal is life saving. The question is whether or not surgical removal of clot improves the ultimate outcome in patients who are stable or even improving. Improvement in function is based on the concept of a penumbra around an ICH. There is now mounting evidence that there is a penumbra of functionally impaired, but potentially reversible, neuronal injury surrounding a haematoma. A pro-active approach must, therefore, be maintained in the management of these patients to salvage as much of this brain as possible. Alert patients with small (< 2 cm) haematomas and moribund patients with extensive haemorrhage may not require surgical evacuation. Indications for clot removal in patients between these extremes are controversial. Current practice favours surgical intervention in the following situations: (i) superficial haemorrhage; (ii) clot volume between 20-80 ml; (iii) worsening neurological status; (iv) relatively young patients; (v) haemorrhage causing midline shift/raised ICP; and (vi) cerebellar haematomas > 3 cm or causing hydrocephalus. A large multicentre prospective randomised controlled trial (International Surgical Trial in Intracerebral Haemorrhage) is currently underway to determine if early clot evacuation will lead to a better neurological outcome in patients with spontaneous supratentorial, non-aneurysmal ICH
((Siddique MS, Mendelow AD. Surgical treatment of intracerebral haemorrhage. Br 
Med Bull. 2000;56(2):444-56. Review. PubMed PMID: 11092093.
))
----



[[Intracerebral hemorrhage surgery ]] is probably indicated for patients with superficial spontaneous lobar supratentorial [[intracerebral hemorrhage]] (ICH) when the level of [[consciousness]] drops below [[glasgow coma scale]] 13 within the first 8 h of the onset of the haemorrhage. 

Haematoma volume is a very important factor in the surgical indication of clot evacuation.

Early surgery may reduce the volume of ICH, local mass effect, herniation, and secondary injury due to ischemia 
((Siddique MS, Fernandes HM, Arene NU, Wooldridge TD, Fenwick JD, Mendelow AD. Changes in cerebral blood flow as measured by HMPAO SPECT in patients following spontaneous intracerebral haemorrhage. Acta Neurochir Suppl. 2000;76:517–520.))
((Menndelow AD. Mechanisms of ischemic brain damage with intracerebral hemorrhage. Stroke. 1993;24(suppl 12):I115–I117; discussion I8-I9.)).

Meta-analysis of 10 trials that have previously assessed the effects of surgery plus routine medical management, compared with routine medical management alone, in patients with primary supratentorial ICH have included 2059 patients
((Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database Syst Rev. 2008;(4):CD000200.)).

Once the level drops below 9, it is probably too late to consider craniotomy for these patients, so clinical vigilance is paramount. While this statement is only backed up by evidence that is moderately strong, meta-analysis of available data suggests that it is true in the rather limited number of patients with ICH. Meta-analyses like this can often predict the results of future prospective randomised controlled trials a decade or more before the trials are completed and published. Countless such examples exist in the literature, as is the case for thrombolysis in patients with myocardial infarction in the last millennium: meta-analysis determined the efficacy more than a decade BEFORE the last trial (ISIS-2) confirmed the benefit of thrombolysis for myocardial infarction
((Mendelow AD. Surgical Craniotomy for Intracerebral Haemorrhage. Front Neurol
Neurosci. 2015;37:148-54. doi: 10.1159/000437119. Epub 2015 Nov 12. Review.
PubMed PMID: 26588582.
)).

===== References =====