Decompressive Hemicraniectomy for Massive Cerebral Hemorrhage
Background: Hemicraniectomy and durotomy has been shown to be a promising treatment for malignant MCA infarction, but has not been evaluated for cerebral hemorrhage. Methods: We analyzed the clinical course and outcome of 15 patients treated with decompressive surgery for space-occupying cerebral hematomas between 9/98 and 6/00. All patients were treated with duroplasty and either hemicraniectomy (n=13) or a “floating” bone flap (n=2); in some patients, hematoma (n=5) and subdural clot (n=2) evacuation was also performed. Outcomes were assessed by telephone interview using the modified Rankin scale (mRS). Results: Mean age was 49 years (range 33–66); 8 were women; the lesion was left-sided in 7. Hematoma formation was related to spontaneous aneurysmal rupture (n=7), intra-operative aneurysmal rupture (n=3), hypertensive intracerebral hemorrhage (n= 3), and hemorrhagic infarction (n=2). Surgery was peformed <24 hours after onset in 5 patients, between 24–48 hours in 6, and between 3–5 days in 4. On the day of surgery, mean hematoma volume was 63 ml (range 6–216 ml), mean GCS was 6.3 (range 4–10), and mean NIHSS was 22 (range 13–28); 5 patients had clinical herniation signs. Postoperative CT scans showed significant reductions in both mean septal shift (from 10.3 to 6.1 mm) and pineal shift (from 6.4 to 3.5 mm) (both P<.02). Eighty percent (12/15) of patients survived to discharge, and one died after discharge. After a mean follow up of 5.7 months (range 1–13), one survivor (9%) had no disability (mRS 0–1), four (36%) had slight or moderate disability (mRS 2–3), and six (54%) had moderate or severe disability (mRS 4–5). Conclusion: Duroplasty and hemicraniectomy, with or without concurrent hematoma evacuation, may improve survival and recovery in comatose patients with large aneurysmal, hypertensive, or infarct-related cerebral hemorrhages.