Indications
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Symptomatic intracerebral hemorrhage (ICH) causing progressive neurologic symptoms or impending cerebral herniation syndromes is best managed with open evacuation, especially in younger patients, in whom there is less atrophy and cerebral compliance to accommodate mass effect.
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ICH that is associated with suspected underlying structural etiology (vascular malformation, tumor, aneurysm) is best managed with open surgical evacuation, allowing evacuation of hematoma and addressing the underlying structural lesion as appropriate. Lobar hemorrhage, especially in younger patients, is more likely associated with underlying structural abnormalities compared with deep ICH, which is more commonly associated with hypertension.
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ICH associated with more diffuse cerebral edema (e.g., in the setting of trauma or hemorrhagic conversion of arterial or venous infarction) is best evacuated by an open approach, which also allows decompression craniectomy and expansive duraplasty if necessary.
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Infratentorial hematomas causing mass effect on the brainstem and hydrocephalus from compression of the fourth ventricle (or extension of bleed to the ventricular system) are best managed by prompt open surgical evacuation.
Contraindications
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Hemorrhages involving deep nuclei are best managed with stereotactic aspiration rather than open surgery.
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Lobar hemorrhages in older patients, without rapid deterioration in neurologic condition or suspected structural lesion, may be managed expectantly or by stereotactic catheter aspiration.
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Surgical evacuation of ICH should not be attempted in the setting of uncorrected coagulopathy or platelet dysfunction.
Planning and positioning
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Initial evaluation of a patient with ICH should involve evaluation with an imaging modality such as computed tomography (CT). In almost all cases, a few additional minutes are taken to obtain computed tomography angiography (CTA) to rule out underlying vascular etiology.
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In stable patients, a more complete diagnostic evaluation is done if CTA provides insufficient information to allow appropriate management of the underlying structural lesion (magnetic resonance imaging [MRI] or formal angiography if tumor [MRI] or aneurysm [angiography] is suspected). In stable patients, fiducial scalp markers or other preparations are undertaken for image-guided planning and execution of the surgery.
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In the presence of a large ICH with associated shift, mannitol (0.5 to 1 g/kg) is administered intravenously, and judicious hyperventilation is instituted after induction of general anesthesia. Prophylactic anticonvulsant is administered in all cases but infratentorial ICH.
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Normotension is instituted and insured especially if underlying aneurysm or vascular malformation is suspected. Blood pressure control should be particularly insured during placement of skull fixation pins and on skin incision.
Figure 34-1:
In the case of a supratentorial hematoma involving the frontoparietal region, the patient is positioned in supine position with the head turned opposite to the side of operation and the neck slightly extended, making the zygoma the highest point of the face. Position is fixed using a three-point Mayfield headrest set. This incision is used for all cases of frontotemporal ICH. Bony exposure at the skull base is indicated to accommodate potential temporal lobe edema, and frontobasal resection of the lesser wing of the sphenoid ( hatched areas ) is indicated to address associated aneurysms. Aneurysms are secured at the same time as ICH evacuation to prevent rebleeding. Resection of associated arteriovenous malformation (AVM) or other vascular anomaly should be planned unless the AVM is complex and requires preparatory embolization. In such cases, bony exposure should be wide enough to accommodate AVM resection at the same or a subsequent procedure.Related posts:
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