Supratentorial ICH

• 
  

  Precise indications for surgery are controversial ^{1 – 4} and should be based on the individual patient’s neurologic condition, the size and location of the hematoma, the patient’s age, and the family’s wishes.

  
  
• 
  

  The 2010 American Stroke Association/American Heart Association (ASA/AHA) guidelines recommend standard craniotomy for lobar clots greater than 30 mL and within 1 cm of surface.

  
  
• 
  

  In general, factors that favor surgical management ⁵ include:

  
  
  
  
  • 
    

    Lesions with marked mass effect, edema, or midline shift;

    
    
  • 
    

    Lesions with symptoms that appear to be secondary to increased intracranial pressure (ICP) or mass effect;

    
    
  • 
    

    Moderate clot volume;

    
    
  • 
    

    Persistently elevated ICP despite maximal medical management;

    
    
  • 
    

    Rapid neurologic deterioration;

    
    
  • 
    

    Favorable locations: lobar, cerebellar, external capsule, nondominant hemisphere;

    
    
  • 
    

    Young age;

    
    
  • 
    

    Onset of symptoms less than 24 hours old.

Infratentorial ICH

• 
  

  2010 ASA/AHA indications for surgical evacuation of cerebellar ICH ¹

  
  
  
  
  • 
    

    Patients who are deteriorating neurologically

    
    
  • 
    

    Brainstem compression

    
    
  • 
    

    Hydrocephalus from ventricular obstruction

Radiographic Imaging

• 
  

  Computed tomography (CT) can be obtained rapidly and clearly demonstrates high density blood within brain parenchyma. In addition, the ellipsoid method (diameter of the clot in each dimension: anteroposterior [AP], lateral [LAT], and height [HT]) can be used to calculate ICH volume and has prognostic significance. ⁶

  
  
  
  
  • 
    

    Ellipsoid volume – AP × LAT × HT/2

  
  
• 
  

  Magnetic resonance imaging (MRI) is not the initial diagnostic imaging modality of choice due to the time needed to complete the study as well as the complicated appearance of acute blood on MRI. ⁷

  
  
• 
  

  CT angiography (CTA) is recommended for all patients except those older than 45 years of age with preexisting hypertension and ICH in the thalamus, putamen, or cerebellum ( Fig. 19.1 ). ⁸ CTA has lower yield for cerebellar ICH in comparison to supratentorial ICH.

  
  
• 
  

  Preoperative imaging ( Fig. 19.2 ).

Initial Management and Medication ^{1 , 2}

• 
  

  Initial monitoring should take place in an intensive care unit or other monitored setting.

  
  
• 
  

  Blood pressure should be promptly but not over-aggressively controlled. In patients presenting with systolic blood pressure (SBP) of 160–220 mm Hg, the authors prefer nicardipine infusion with a goal SBP of 140–160 mm Hg.

  
  
• 
  

  For patients with clinical seizures or electroencephalography (EEG) evidence of seizure activity, the authors prefer phenytoin. Although seizure prophylaxis is debated in the setting of ICH, the authors also prefer phenytoin for the prevention of early seizures in patients with lobar ICH.

  
  
• 
  

  Glucose should be monitored and normoglycemia maintained.

  
  
• 
  

  Platelet transfusion and factor replacement should be given to all patients with severe thrombocytopenia or coagulation factor deficiency, respectively. For patients with a coagulopathy, consideration should be given to giving protamine sulfate, vitamin K, fresh frozen plasma, cryoprecipitate, or other clotting factors. For patients with a history of antiplatelet medication use, the authors prefer desmopressin acetate alone for those undergoing conservative management and desmopressin plus platelet transfusion for those undergoing surgical management. Currently recombinant factor VIIa (rFVIIa) is not recommended given its thromboembolic risk. ⁹

  
  
• 
  

  Regarding the prevention of deep venous thrombosis and pulmonary embolism, all patients should have intermittent pneumatic compression, and pharmacological prophylaxis should be considered once cessation of bleeding has been documented.

  
  
• 
  

  Treatment of elevated ICP should begin with simple measures such as head of bed elevation, analgesia, and sedation. More aggressive measures to reduce ICP include osmotic diuresis, cerebrospinal fluid (CSF) drainage, paralysis, hyperventilation, hypothermia, and barbiturate coma.

  
  
• 
  

  Patients with obstructive hydrocephalus should undergo emergent placement of an external ventricular drain (EVD) in the intensive care unit prior to surgery. Alternatively, an EVD may be placed in the operating room at the time of surgery as long as this is done expeditiously.

  
  
• 
  

  In the authors’ experience, upward cerebellar herniation due to EVD over-drainage is extremely rare. Nonetheless, EVD drainage should be limited by setting a gradient no less than 10 cm H₂O prior to surgery.

Operative Field Preparation

• 
  

  The exposed skin is sterilized with povidone iodine or chlorhexidine application.

  
  
• 
  

  The incision is marked and infiltrated with 1% lidocaine with epinephrine 1:100,000.

Frontal Craniotomy ¹⁰

Positioning and Skin Incision (Fig. 19.3)

Subcutaneous Dissection (Fig. 19.4)

Craniotomy (Fig. 19.5)

Related posts:

22 Pituitary Apoplexy 21 Ventricular Shunt Malfunction 20 Surgery for Acute Intracranial Infection 7 Invasive Neuromonitoring Techniques 18 Treatment of Acute Cauda Equina Syndrome 23 Combat Cranial Operations

Stay updated, free articles. Join our Telegram channel

Join