Decompressive Hemicraniectomy in ICH With ICP Crisis
Decompressive Hemicraniectomy in ICH With ICP Crisis
Object. Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.
Methods. From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.
Results. The patients' median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm (range 28–79 cm), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm, age < 60 years) whose cases were managed nonoperatively (n = 5).
Conclusions. Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.
Intracerebral hemorrhage is a devastating stroke subtype accounting for 10%–15% of all strokes, with 30-day mortality rates ranging from 23% to 52%. Large ICHs have particularly poor outcomes; 30-day mortality rates for patients with ICH volumes greater than 50–60 cm range from 81% to 91%, and poor functional outcome rates of 96%–97% have been reported for those with ICH volumes greater than 40–45 cm The primary etiological mechanism for injury following large ICH is intracranial hypertension and resultant herniation.
Decompressive craniectomy is a surgical technique designed to provide instantaneous and definitive relief of elevated ICP. Although some regard DHC as a last-ditch effort—only to be used when more conservative ICP treatment measures have failed—evidence suggests that decompression may play an important role in the optimal care of patients with elevated ICP. While the evidence for decompressive craniectomy in ICH is relatively poor, it has proven to be beneficial in analogous conditions, including traumatic brain injury, poor grade subarachnoid hemorrhage, and malignant ischemic stroke. Results of decompressive craniectomy combined with clot evacuation in a total of 138 ICH patients have been retrospectively reported in the literature. On average these patients had a mortality of 29%, with a follow-up period ranging from discharge to 2 years.
We present a preliminary series of 5 cases in which clot evacuation was not attempted due to the fact that all clots were deep and in the dominant hemisphere. We hope these data will help isolate the effect of DHC without clot evacuation.
Abstract and Introduction
Abstract
Object. Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.
Methods. From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.
Results. The patients' median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm (range 28–79 cm), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm, age < 60 years) whose cases were managed nonoperatively (n = 5).
Conclusions. Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.
Introduction
Intracerebral hemorrhage is a devastating stroke subtype accounting for 10%–15% of all strokes, with 30-day mortality rates ranging from 23% to 52%. Large ICHs have particularly poor outcomes; 30-day mortality rates for patients with ICH volumes greater than 50–60 cm range from 81% to 91%, and poor functional outcome rates of 96%–97% have been reported for those with ICH volumes greater than 40–45 cm The primary etiological mechanism for injury following large ICH is intracranial hypertension and resultant herniation.
Decompressive craniectomy is a surgical technique designed to provide instantaneous and definitive relief of elevated ICP. Although some regard DHC as a last-ditch effort—only to be used when more conservative ICP treatment measures have failed—evidence suggests that decompression may play an important role in the optimal care of patients with elevated ICP. While the evidence for decompressive craniectomy in ICH is relatively poor, it has proven to be beneficial in analogous conditions, including traumatic brain injury, poor grade subarachnoid hemorrhage, and malignant ischemic stroke. Results of decompressive craniectomy combined with clot evacuation in a total of 138 ICH patients have been retrospectively reported in the literature. On average these patients had a mortality of 29%, with a follow-up period ranging from discharge to 2 years.
We present a preliminary series of 5 cases in which clot evacuation was not attempted due to the fact that all clots were deep and in the dominant hemisphere. We hope these data will help isolate the effect of DHC without clot evacuation.
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