Natural History and Surgical Management of Spontaneous Intracerebral Hemorrhage

3 Natural History and Surgical Management of Spontaneous Intracerebral Hemorrhage

Jonathan Rychen and David Bervini

Abstract

The following chapter provides a literature review on the natural history and management options of spontaneous intracerebral hemorrhage (ICH). ICH is associated with high morbidity/mortality risks and requires evidence-based management. Tremendous efforts have been made to produce high-level evidence studies. The most important trials are discussed in this chapter. For many ICH cases, the presented reviewed literature allows to define surgical and conservative candidates. However, there are still some ICH cases “in between,” where management remains controversial. The different surgical and medical management options are reviewed.

Keywords: spontaneous intracerebral hemorrhage stroke natural history conservative therapy surgical therapy neurosurgery outcome

3.1 Introduction

Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke (the second most common form of stroke, accounting for 9–27% of all strokes) and is associated with high mortality and morbidity risks (the most deadly form of stroke).1^, ²^, ³ The term spontaneous is meant to specify ICH in the absence of trauma or underlying structural lesions. The overall incidence of spontaneous ICH is 24.6 per 100,000 person-years and increases with age, with a slight male preponderance.³

The clinical presentation of acute ICH includes focal neurological deficits, headache, vomiting, impaired consciousness, and epilepsy. Neuroimaging with computed tomography (CT; Fig. 3.1) or magnetic resonance imaging (MRI) is necessary to confirm the diagnosis. Contrast-enhanced CT or MR and CT or MR angiography/venography as well as catheter angiography are useful to look at underlying structural lesions. Possible underlying structural lesions causing ICH include cerebral aneurysms, arteriovenous malformations and fistulas, cavernous angiomas, venous thrombosis, and tumors (primary or metastatic neoplasia). It is important to distinguish spontaneous ICH from hemorrhages due to an underlying vascular etiology such as cerebral aneurysm or arteriovenous malformation rupture because these different entities develop at a different bleeding pressure and have different natural histories.

Fig. 3.1 Intracerebral hemorrhage. Axial native computed tomography (CT) scan demonstrating a hyperdense lesion in the right temporal lobe, corresponding to an acute spontaneous intracerebral hemorrhage.

This chapter focuses on the natural history and management options for spontaneous ICH without underlying structural lesions. This subgroup of spontaneous ICH is mainly caused by the following:

●Hypertension.

●Amyloid angiopathy.

●Clotting disorders.

●Recreational drugs (e.g., cocaine).

●Hemorrhagic conversion of an ischemic stroke.

In the cases where no underlying cause is identified with currently available diagnostic tools, spontaneous ICH may be considered cryptogenic or sine materia.

3.2 Selected Papers on the Natural History of Spontaneous ICHs

●van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010;9(2):167–176

●Mendelow AD, Gregson BA, Fernandes HM, et al; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365(9457):387–397

●Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM; STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013;382(9890):397–408

3.3 Natural History of Spontaneous ICHs

A total of 24 studies 4^, ⁵^, ⁶^, ⁷^, ⁸^, ⁹^, ¹⁰^, ¹¹^, ¹²^, ¹³^, ¹⁴^, ¹⁵^, ¹⁶^, ¹⁷^, ¹⁸^, ¹⁹^, ²⁰^, ²¹^, ²²^, ²³^, ²⁴^, ²⁵^, ²⁶^, ²⁷ related to the natural history and 64 studies⁴^, ⁵^, ⁶^, ⁷^, ⁸^, ⁹^, ¹⁰^, ¹¹^, ¹²^, ¹³^, ¹⁴^, ¹⁶^, ¹⁷^, ¹⁸^, ¹⁹^, ²⁰^, ²¹^, ²²^, ²³^, ²⁴^, ²⁶^, ²⁸^, ²⁹^, ³⁰^, ³¹^, ³²^, ³³^, ³⁴^, ³⁵^, ³⁶^, ³⁷^, ³⁸^, ³⁹^, ⁴⁰^, ⁴¹^, ⁴²^, ⁴³^, ⁴⁴^, ⁴⁵^, ⁴⁶^, ⁴⁷^, ⁴⁸^, ⁴⁹^, ⁵⁰^, ⁵¹^, ⁵²^, ⁵³^, ⁵⁴^, ⁵⁵^, ⁵⁶^, ⁵⁷^, ⁵⁸^, ⁵⁹^, ⁶⁰^, ⁶¹^, ⁶²^, ⁶³^, ⁶⁴^, ⁶⁵^, ⁶⁶^, ⁶⁷^, ⁶⁸^, ⁷⁰ related to surgical management of spontaneous ICH are summarized in Table 3.1. In all, 13,026 cases (conservatively and surgically treated ICH, supra- and infratentorial ICH) in 66 studies eligible for the systematic review were included in the analysis. The mean age at presentation of ICH was 59 years (range: 12–94 years) with a slight male preponderance (56%). Fig. 3.2 demonstrates the common locations of ICH. Spontaneous hemorrhage was most commonly located in the basal ganglia and/or the thalamus (64.8%). ICH was associated with intraventricular hematoma in 21.6% of cases. This was usually related to deep-seated ICH in the basal ganglia and/or the thalamus. In 46% of cases, the hematoma was in the left hemisphere. Considerable hematoma expansion after initial CT scan occurred in 7% of the patients.

Table 3.1 Pooled literature analysis on the natural history and surgical outcomes following spontaneous intracerebral hemorrhages

Study	Study type	Treatment	No. of patients	Type of surgical treatment (n)	Death (n)	Favorable outcome (n)
Liliang et al¹⁵	RCS	Conservative	36		3	24^a
Yildiz et al²⁵	RCS	Conservative	153		NR	NR
Auer et al⁴	RCT	Conservative	50		35	NR
Auer et al⁴	RCT	Surgical	50	End (50)	21	NR
Batjer et al⁵	RCT	Conservative	13		11	2^b
Batjer et al⁵	RCT	Surgical	8	Cra (8)	4	2^b
Bilbao et al⁶	PNRS	Conservative	276		115	NR
Bilbao et al⁶	PNRS	Surgical	80	Cra (58), StA (1), BH (1), Oth (20)	42	NR
Cho et al⁷	RCS	Conservative	201		NR	NR
Cho et al⁷	RCS	Surgical	199	Cra (101), End (74), StA (24)	NR	NR
Fujitsu et al⁸	PNRS	Conservative	111		NR	NR
Fujitsu et al⁸	PNRS	Surgical	69	Cra (69)	NR	NR
Guo et al⁹	RCS	Conservative	3,007		321	NR
Guo et al⁹	RCS	Surgical	226	NR	61	NR
Jang et al¹⁰	RCS	Conservative	195		94	18^c
Jang et al¹⁰	RCS	Surgical	86	StA (35), DCraHE (16), Cra (2), Oth (33)	16	9^c
Juvela et al¹¹	RCT	Conservative	26		10	5^a
Juvela et al¹¹	RCT	Surgical	26	NR	12	1^a
Kanno et al¹²	RCS	Conservative	305		NR	NR
Kanno et al¹²	RCS	Surgical	154	NR	NR	NR
Kaya et al¹³	RCS	Conservative	19		12	0^a
Kaya et al¹³	RCS	Surgical	47	Cra (47)	16	0^a
Kobayashi et al¹⁴	RCS	Conservative	65		NR	NR
Kobayashi et al¹⁴	RCS	Surgical	36	DCraHE (36)	NR	NR
Liu et al¹⁶	RCS	Conservative	181		31	NR
Liu et al¹⁶	RCS	Surgical	129	Cra (129)	18	NR
Lo et al¹⁷	RCS	Conservative	72	31		5^a; 10^b
Lo et al¹⁷	RCS	Surgical	54	DCraHE (49), DCra (5)	16	0^a; 13^b
Melamed et al¹⁸	RCS	Conservative	15		7	8^a
Melamed et al¹⁸	RCS	Surgical	2	DCraHE (2)	1	1^a
Mendelow et al¹⁹	RCT	Conservative	530		189	118^a
Mendelow et al¹⁹	RCT	Surgical	503	Cra (346), BH (37), End (31), StA (34), Oth (55)	173	122^a
Mendelow et al²⁰	RCT	Conservative	292		69	108^a
Mendelow et al²⁰	RCT	Surgical	305	Cra (284), Oth (21)	54	123^a
Sumer et al²¹	PNRS	Conservative	46		5	30^a
Sumer et al²¹	PNRS	Surgical	1	DCraHE (1)	1	0^a
Tan et al²²	PNRS	Conservative	17		6	NR
Tan et al²²	PNRS	Surgical	17	Cra (17)	8	NR
Wang et al²³	RCT	Conservative	234		45	29^a
Wang et al²³	RCT	Surgical	266	NR	31	21^a
Xu and Hai²⁴	RCT	Conservative	50		NR	NR
Xu and Hai²⁴	RCT	Surgical	50	StA (50)	NR	NR
Zuccarello et al²⁶	RCT	Conservative	11		3	4^b
Zuccarello et al²⁶	RCT	Surgical	9		2	5^b
Hanley et al²⁸	RCT	Conservative	42		4	6^c
Hanley et al²⁸	RCT	Surgical	54	StA (54)	8	8^c
Barrett et al²⁹	RCS	Surgical	15	StA (15)	2	NR
Bauer et al³⁰	PNRS	Surgical	18	Oth (18)	1	NR
Chen and Feng³¹	RCS	Surgical	322	NR	NR	NR
Chi et al³²	RCS	Surgical	1,310	Cra (312), BH (298), End (144), StA (475), Oth (81)	241	NR
Esquenazi et al³³	PNRS	Surgical	73	DCraHE (63), DCra (10)	20	11^a
Fu et al³⁴	RCS	Surgical	267	IVF (267)	NR	NR
Gao et al³⁵	RCS	Surgical	106	Cra (106)	7	NR
Goedemans et al³⁶	RCS	Surgical	29	DCra (15), DCraHE (14)	NR	9^b
Hayes et al³⁷	RCS	Surgical	51	Cra (33), DCraHE (18)	15	15^c
Hinson et al³⁸	RCS	Surgical	14	IVF (8), Oth (6)	6	NR
Jianwei et al³⁹	RCS	Surgical	28	Cra (28)	NR	NR
Kim et al⁴⁰	RCS	Surgical	24	DCraHE (24)	6	12^b
Kwon et al⁴¹	RCS	Surgical	47	StA (47)	2	16^b
Labib et al⁴²	PNRS	Surgical	39	Oth (39)	0	22^c
Ma et al⁴³	RCS	Surgical	84	DCraHE (46), Cra (38)	32	1^a
Marquardt et al⁴⁴	PNRS	Surgical	64	StA (64)	2	NR
Matsumoto and Hondo⁴⁵	RCS	Surgical	51	StA (51)	7	12^a
Moussa and Khedr⁴⁶	RCT	Surgical	40	DCraHE (20), Cra (20)	7	18^a
Murthy et al⁴⁷	RCS	Surgical	12	DCraHE (12)	1	5^d
Naff et al⁴⁸	RCT	Surgical	48	IVF (26), Other (22)	10	NR
Niizuma et al⁴⁹	RCS	Surgical	190	StA (175), Cra (15)	NR	NR
Piotrowski and Rochowanski⁵⁰	RCS	Surgical	275	Cra (275)	NR	NR
Rehman et al⁵¹	RCS	Surgical	27	Cra (27)	6	NR
Sadahiro et al⁵²	PNRS	Surgical	10	End (10)	0	0^a
Takeda et al⁵³	RCS	Surgical	25	Cra (20), DCraHE (5)	NR	NR
Shin et al⁵⁴	RCS	Surgical	45	Cra (45)	14	0^a
Singh et al⁵⁵	RCS	Surgical	28	DCraHE (28)	10	NR
Spiotta et al⁵⁶	RCS	Surgical	29	End (29)	4	NR
Staykov et al⁵⁷	PNRS	Surgical	32	IVF (32)	5	13^d
Takeuchi et al⁵⁸	RCS	Surgical	21	DCraHE (21)	4	6^b
Vespa et al⁵⁹	RCT	Surgical	14	End (14)	1	6^c
Wang et al⁶⁰	PNRS	Surgical	104	StA (70), End (34)	32	48^b
Wang et al⁶¹	RCS	Surgical	309	StA (309)	44	NR
Wu et al⁶²	RCS	Surgical	126	StA (126)	NR	NR
Yadav et al⁶³	PNRS	Surgical	25	End (25)	6	13^a
Yang et al⁶⁴	RCS	Surgical	21	StA (21)	0	20^a
Yang and Shao⁶⁵	RCT	Surgical	156	StA (78), Cra (78)	NR	NR
Fei et al⁶⁶	RCS	Surgical	112	NR	NR	NR
Zhang et al⁶⁷	RCS	Surgical	33	DCraHE (33)	8	5^a
Zhao et al⁶⁸	PNRS	Surgical	296	DCraHE (127), Cra (116), StA (53)	63	151^b
Ziai et al⁶⁹	RCS	Surgical	12	IVF (12)	1	NR
Zuo et al⁷⁰	RCS	Surgical	176	End (176)	NR	NR
Total (n; %)	RCS (40; 60%) PNRS (13; 20%) RCT (13; 20%)	Conservative (5,947; 46%) Surgical (7,079; 54%)		Cra (2,211; 38%), StA (1,682; 29%), End (553; 9.5%), DCraHE (515; 9%), IVF (345; 6%), BH (336; 6%), DCra (30; 0.5%), Oth (101; 2%)	Conservative (991; 20% [95% CI: 14–26]) Surgical (1,041; 21% [95% CI: 15–27])	Conservative (362; 24% [95% CI: 14–34]) Surgical (688; 29% [95% CI: 21–37])
Abbreviations: BH, burr hole or keyhole craniotomy; CI, confidence interval; Cra, craniotomy; DCra, decompressive craniectomy alone; DCraHE, decompressive craniectomy and hematoma evacuation; End, endoscopy; IVF, intraventricular fibrinolysis with EVD; NR, not reported; Oth, other; PNRS, prospective nonrandomized study; RCS, retrospective case series; RCT, randomized controlled trial; StA, stereotactic or CT-guided aspiration. ^aFavorable outcome defined as Glasgow Outcome Scale (GOS) ≥ 5. ^bFavorable outcome defined as GOS ≥ 4. ^cFavorable outcome defined as modified Rankin scale (mRS) ≤ 3. ^dFavorable outcome defined as mRS ≤ 2.

Fig. 3.2 Location of intracerebral hemorrhage (ICH): basal ganglia and/or thalamus (n = 6,417), intraventricular (n = 2,134), lobar (n = 1,569), brainstem (n = 349), lobar and basal ganglia (n = 228), and cerebellar (n = 176). The sum of percentages is not equal to 100% because patients can be classified to more than one location category.

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