Introductory Chapter: Neurosurgical Management of Intracerebral Hemorrhage

1. Introduction

Primary spontaneous intracerebral haemorrhage (SICH) can lead to fatal outcomes and in survivors can be cause of significant morbidity and long-term disability [1]. In up to 90% patient’s arterial hypertension or amyloid angiopathy gas been attributed as the cause of bleeding [2]. Important points to differentiate primary SICH from secondary SICH include primary SICH usually involve basal ganglia, thalamus in patients with history of hypertension [2, 3, 4, 5]. The increase in life expectancy and increase in aging population it can be anticipated the burden of SICH shall continue to increase [6, 7] with an increase in overall lifetime cost for management of these patients [8]. The role of neurosurgical intervention and available options in the management of spontaneous SICH is not only increasing but also able to improve overall outcomes. We exclude the discussion for the management of spontaneous cerebellar hematomas as these are special subtypes have relative better clinical outcome [2].

2. Clinical characteristics

Each patient needs to evaluated in details including details clinical history and clinical examination particularly neurological deficits and extent of the deficits [2]. Clinical characteristics of the SICH depends on the size, location of the bleed presence or absence of hydrocephalus. General manifestations include sign of raised intracranial pressure i.e., headache, vomiting, seizures, and altered levels of consciousness (including coma in severe cases) [2]. The two common risk factors for SICH include systemic arterial hypertension and cerebral amyloid angiopathy [9, 10].

3. Diagnosis

Primary SICH needs to be differentiated from other causes of haemorrhages i.e., from secondary SICH (for example traumatic ICH, tumours with haemorrhage, vascular malformations, and pharmacological causes of SICH) [2]. Whenever a SICH is suspected, CT scan brain will provide the details regarding presence of blood including its location with sensitivity of more than 95%, in some patients [11, 12] CT scan may not show the blood, in these cases MR can help in finding the blood particularly with T2* and proton weighted sequences [12, 13]. In cases where a secondary cause of intracerebral haemorrhage is suspected CT and MR can be supplemented with MR-angiography, CT-angiography, or if necessary conventional digital subtraction angiography [11].

4. Management

Management may range from medical management and observation alone to aggressive surgical intervention that may include evacuation of the hematoma and/or decompressive craniectomy [14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26]. Standard conservative management and management of patient who is a candidate for surgery include stabilization of airway, breathing, circulation stabilization, control of blood pressure followed by measures to reduce intracranial pressure either anti-oedema measures or surgical evacuation of the hematoma and prevention of secondary complications (pneumonia, DVT, urinary tract infection, pressure ulcers) [27]. For example, surgery may not be advisable in patients with large thalamic haemorrhages or haemorrhages extending into the brain stem in a patient who has poor neurological grade [2].

5. Surgical management

In addition to medical management options, a range of several invasive neurosurgical approaches have been described for clot removal and to reduce mass effect. These approached include open craniotomy to evacuate hematoma with or without decompressive craniectomy, image-guided stereotactic endoscopic aspiration, minimally invasive methods for thrombolysis and placement of external ventricular drainage (in cases of intraventricular extension of the clot of associated hydrocephalus) have been described [27]. Decision to perform surgery can be influenced by the facilities available, expertise and patient related factors, the surgical options include open craniotomy and evacuation of the hematoma, endoscopic evacuation of the hematoma, stereotactic evacuation of the hematoma, CSF diversion procedures like EVD of VP shunt if there in extension into the ventricles or associated obstructive hydrocephalus.

6. Scope of neurosurgical intervention

The role of neurosurgical interventions has been expanding in the management of SICH however there are many challenges ahead and many questions needs to be answered. For example, any follow up intervention cannot reverse the primary injury [27] but at the same time it can help to minimize secondary injury. Evacuating the hematoma can be a lifesaving procedure, however there is a need to further understand how can we improve the overall quality of life of the survivors. The decision to perform surgical evacuation can be weighed in a case-to-case basis. For examples Reichart [2].

• Small haemorrhages involving basal ganglia with minimal or absent neurological deficits can be managed conservatively

• In large hematomas where a whole hemisphere is involved, patient is an elderly with poor neurological grade, surgery may be lifesaving but prognosis remains poor hence surgery may not be advisable

• Conscious patients with hematomas between 30 and 50 ml, deep location and without mass effect can be managed conservatively. However, if secondary neurological deterioration occurs and the volume of hematoma increases and size may be of 50–60 ml, open craniotomy and evacuating of the hematoma can be considered

• Young patients with a moderate or large lobar haemorrhage who are clinically deteriorating may need surgical intervention

• SICH associated with a structural lesion such as an aneurysm, arteriovenous malformation or cavernous angioma may need surgical intervention.

7. Challenges

Although recent advancements both in terms of medical and surgical management of these patients have resulted in improved survivals however overall functional outcomes remains compromised [27, 28, 29, 30, 31, 32, 33, 34]. Many studies have explored the role of surgery in the management of spontaneous intracerebral hematomas [35]. However, the generalization of the results and management of individual patients remains both controversial and challenging.

8. Conclusions

There is a need for evidence-based algorithms which can better address management options as well as overall functional outcomes of these patients, where the individual patient regain functional independence as well as can be integrated into the society. As investigators, in addition to the development of post event management protocols and factors facilitating the neuronal recovery, but also to focus on techniques those can detect high risk patients to develop SICH and strategies like risk factor modifications to prevent episodes of SICH which can potentially be fatal or can leave the patients with severe disability.