Traumatic intracerebral hemorrhage surgery
Traumatic intracerebral hemorrhage (t-ICH) surgery is a medical procedure performed to treat severe brain injuries resulting from head trauma. It involves the surgical removal or evacuation of blood that has accumulated within the brain tissue due to injury. Here's an overview of t-ICH surgery:
Indications for Surgery: Surgery for t-ICH is typically considered when there is a significant amount of bleeding within the brain, causing increased pressure inside the skull. The decision to perform surgery is based on factors such as the size and location of the hemorrhage, the patient's neurological status, and the risk of further damage if the bleeding continues.
Surgical Techniques: Several surgical techniques may be used to address t-ICH:
Craniotomy: A craniotomy involves the removal of a portion of the skull to access the bleeding site. This allows the surgeon to directly evacuate the blood clot and relieve pressure on the brain. Once the hemorrhage is addressed, the bone flap may be replaced and secured with plates, screws, or other materials.
Minimally Invasive Procedures: In some cases, minimally invasive techniques, such as endoscopic surgery or stereotactic aspiration, may be used. These methods involve making smaller incisions or using image-guided technology to access and remove the blood clot.
Goals of Surgery: The primary goals of t-ICH surgery are as follows:
Hemorrhage Evacuation: The surgical team aims to remove the accumulated blood from the brain tissue to relieve pressure and reduce the risk of further damage.
Preventing Complications: Surgery can help prevent complications associated with elevated intracranial pressure, such as brain herniation, which can be life-threatening.
Postoperative Care: After t-ICH surgery, patients are closely monitored in an intensive care unit (ICU). Postoperative care includes:
Neurological Monitoring: Continuous assessment of the patient's neurological status to detect any changes or complications.
Control of Intracranial Pressure: Measures to manage intracranial pressure, including medications and, in some cases, draining cerebrospinal fluid.
Preventing Infections: Infection prevention is crucial, as the brain is a sensitive organ. Antibiotics may be administered to reduce the risk of infection.
Rehabilitation: Depending on the extent of the injury, patients may require rehabilitation to regain lost motor and cognitive function.
Outcomes: The outcomes of t-ICH surgery vary depending on factors such as the severity of the initial injury, the timing of surgery, and the patient's overall health. Some patients may experience significant improvements in neurological function, while others may face long-term challenges.
It's important to note that not all cases of t-ICH require surgery, and the decision to proceed with surgery is made on a case-by-case basis by a team of medical professionals, including neurosurgeons and neurologists.
Overall, t-ICH surgery is a critical intervention aimed at addressing life-threatening brain hemorrhages and improving the chances of recovery in patients with traumatic brain injuries.
van Erp et al. found that the choice between early surgery and conservative treatment for traumatic intracerebral hemorrhage depends on the severity of the brain injury and whether the t-ICH is isolated or not. Early surgery might be more beneficial for those with moderate TBI and isolated t-ICH. On the other hand, conservative treatment might be a better option for patients with mild TBI and smaller t-ICH. These findings align with the results of another trial called the STITCH(Trauma) trial, which studied a similar question 1).
Surgical treatment of traumatic intracerebral lesions was advanced in the late 19th and 20th centuries by several pioneer neurosurgeons, including Victor Horsley, Harvey Cushing, W H Jacobson, Hugh Cairns, and Walter Dandy.
In 2006 there was Level III 2):
Indications for surgical evacuation for TICH:
○ progressive neurological deterioration referable to the TICH, medically refractory IC-HTN, or signs of mass effect on CT
○ or TICH volume > 50cm3 cc or ml
○ or GCS = 6–8 with frontal or temporal TICH volume >20 cm3 with midline shift(MLS)≥5mm and/or compressed basalcisterns on CT.
● nonoperative management with intensive monitoring and serial imaging: may be used for TICH without neurologic compromise and no significant mass e ect on CT and controlled ICP.
While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition.
OBJECTIVES: There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment.
DESIGN: This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service.
SETTING: Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study.
PARTICIPANTS: The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury.
INTERVENTIONS: Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate.
MAIN OUTCOME MEASURES: The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale.
RESULTS: Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively).
CONCLUSIONS: This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted.
TRIAL REGISTRATION: Current Controlled Trials ISRCTN 19321911 3).