(Stroke. 1999;30:1833-1839.)
© 1999 American Heart Association, Inc.
Original Contributions |
Early Surgical Treatment for Supratentorial Intracerebral Hemorrhage
A Randomized Feasibility Study
From the Departments of Neurosurgery (M.Z., J.T., H. Van L., H-S.Y.), Neurology (L.S., J.B.), Emergency Medicine (R.K., A.P.), Radiology (T.T.), and Environmental Health (J.K.), University of Cincinnati Medical Center (Ohio); Department of Neurology, Mayo Clinic, Jacksonville, Fla (T.B.); and Service de Neurologie, Hopitaux de Lyon, Lyon, France (L.D.).
Correspondence to Joseph Broderick, MD, University of Cincinnati Medical Center, Department of Neurology, 231 Bethesda Ave, Cincinnati, OH 45267-0525. E-mail broderjp{at}ucsm
Background and Purpose—The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH.
Methods—Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm3 on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3.
Results—Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04).
Conclusions—Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.
Key Words: craniotomy • intracerebral hemorrhage • medical management • stereotaxic aspiration • surgical treatment
This article has been cited by other articles:
 |
|
 |
|
  Y.-C. Chuang, Y.-M. Chen, S.-K. Peng, and S.-Y. Peng Risk stratification for predicting 30-day mortality of intracerebral hemorrhage Int. J. Qual. Health Care, December 1, 2009; 21(6): 441 - 447. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Broderick, S. Connolly, E. Feldmann, D. Hanley, C. Kase, D. Krieger, M. Mayberg, L. Morgenstern, C. S. Ogilvy, P. Vespa, et al. REPRINT: 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: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation, October 16, 2007; 116(16): e391 - e413. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. M. Thompson, S. Y. Gerlach, H. K. S. Jorn, J. M. Larson, T. G. Brott, and J. A. Files Advances in the Care of Patients With Intracerebral Hemorrhage Mayo Clin. Proc., August 1, 2007; 82(8): 987 - 990. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Broderick, S. Connolly, E. Feldmann, D. Hanley, C. Kase, D. Krieger, M. Mayberg, L. Morgenstern, C. S. Ogilvy, P. Vespa, 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: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke, June 1, 2007; 38(6): 2001 - 2023. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. S. Kase Hemostatic Treatment in the Early Stage of Intracerebral Hemorrhage: The Recombinant Factor VIIa Experience Stroke, October 1, 2005; 36(10): 2321 - 2322. [Full Text] [PDF]
|
|
|
|
|
|
J. P. Broderick The STICH Trial: What Does It Tell Us and Where Do We Go From Here? Stroke, July 1, 2005; 36(7): 1619 - 1620. [Full Text] [PDF]
|
|
|
|
 |
|
 M Castellanos, R Leira, J Tejada, A Gil-Peralta, A Davalos, J Castillo, and for the Stroke Project, Cerebrovascular Diseases G Predictors of good outcome in medium to large spontaneous supratentorial intracerebral haemorrhages J. Neurol. Neurosurg. Psychiatry, May 1, 2005; 76(5): 691 - 695. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. M. Manno, J. L. D. Atkinson, J. R. Fulgham, and E. F. M. Wijdicks Emerging Medical and Surgical Management Strategies in the Evaluation and Treatment of Intracerebral Hemorrhage Mayo Clin. Proc., March 1, 2005; 80(3): 420 - 433. [Abstract] [PDF]
|
|
|
|
|
|
NINDS ICH Workshop Participants Priorities for Clinical Research in Intracerebral Hemorrhage: Report From a National Institute of Neurological Disorders and Stroke Workshop Stroke, March 1, 2005; 36(3): e23 - e41. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. D. Freeman, T. G. Brott, K. M. Barrett, P. R. Castillo, H. G. Deen Jr, L. F. Czervionke, and J. F. Meschia Recombinant Factor VIIa for Rapid Reversal of Warfarin Anticoagulation in Acute Intracranial Hemorrhage Mayo Clin. Proc., December 1, 2004; 79(12): 1495 - 1500. [Abstract] [PDF]
|
|
|
|
|
|
B. A. Gregson and A. D. Mendelow International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage Stroke, November 1, 2003; 34(11): 2593 - 2597. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. J. Hankey Evacuation of Intracerebral Hematoma Is Likely to Be Beneficial--Against Stroke, June 1, 2003; 34(6): 1568 - 1569. [Full Text] [PDF]
|
|
|
|
 |
|
 P. M. Vespa, K. O'Phelan, M. Shah, J. Mirabelli, S. Starkman, C. Kidwell, J. Saver, M. R. Nuwer, J. G. Frazee, D. A. McArthur, et al. Acute seizures after intracerebral hemorrhage: A factor in progressive midline shift and outcome Neurology, May 13, 2003; 60(9): 1441 - 1446. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O.P.M. Teernstra, S.M.A.A. Evers, J. Lodder, P. Leffers, C.L. Franke, and G. Blaauw Stereotactic Treatment of Intracerebral Hematoma by Means of a Plasminogen Activator: A Multicenter Randomized Controlled Trial (SICHPA) Stroke, April 1, 2003; 34(4): 968 - 974. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. R. Carhuapoma, P. B. Barker, D. F. Hanley, P. Wang, and N. J. Beauchamp Human Brain Hemorrhage: Quantification of Perihematoma Edema by Use of Diffusion-Weighted MR Imaging AJNR Am. J. Neuroradiol., September 1, 2002; 23(8): 1322 - 1326. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Gebel and W. J. Powers Emergency craniotomy for intracerebral hemorrhage: When doesn't it help and does it ever help? Neurology, May 14, 2002; 58(9): 1325 - 1326. [Full Text] [PDF]
|
|
|
|
|
|
A. A. Rabinstein, J. L. Atkinson, and E. F.M. Wijdicks Emergency craniotomy in patients worsening due to expanded cerebral hematoma: To what purpose? Neurology, May 14, 2002; 58(9): 1367 - 1372. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Xi, Y. Hua, R. R. Bhasin, S. R. Ennis, R. F. Keep, and J. T. Hoff Mechanisms of Edema Formation After Intracerebral Hemorrhage: Effects of Extravasated Red Blood Cells on Blood Flow and Blood-Brain Barrier Integrity Stroke, December 1, 2001; 32(12): 2932 - 2938. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. J. PROVENCIO, T. P. BLECK, and A. F. CONNORS Jr. Critical Care Neurology Am. J. Respir. Crit. Care Med., August 1, 2001; 164(3): 341 - 345. [Full Text] [PDF]
|
|
|
|
|
|
L.B. Morgenstern, A.M. Demchuk, D.H. Kim, R.F. Frankowski, and J.C. Grotta Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage Neurology, May 22, 2001; 56(10): 1294 - 1299. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. I. Qureshi, S. Tuhrim, J. P. Broderick, H. H. Batjer, H. Hondo, and D. F. Hanley Spontaneous Intracerebral Hemorrhage N. Engl. J. Med., May 10, 2001; 344(19): 1450 - 1460. [Full Text] [PDF]
|
|
|
|
|
|
J. C. Hemphill III, D. C. Bonovich, L. Besmertis, G. T. Manley, S. C. Johnston, and S. Tuhrim The ICH Score : A Simple, Reliable Grading Scale for Intracerebral Hemorrhage Editorial Comment: A Simple, Reliable Grading Scale for Intracerebral Hemorrhage Stroke, April 1, 2001; 32(4): 891 - 897. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. M. Fernandes, B. Gregson, S. Siddique, and A. D. Mendelow Surgery in Intracerebral Hemorrhage : The Uncertainty Continues Stroke, October 1, 2000; 31(10): 2511 - 2516. [Abstract] [Full Text] [PDF]
|
|